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Early childhood before, during and after war and displacement in northern Uganda McElroy, Theresa 2012

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EARLY CHILDHOOD BEFORE, DURING AND AFTER WAR AND DISPLACEMENT IN NORTHERN UGANDA   by   THERESA MCELROY  B.Sc.O.T., The University of British Columbia, 1998 M.I.H., Curtin University of Science and Technology, 2006  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Interdisciplinary Studies)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  April 2012  © Theresa McElroy, 2012 ii  Abstract Background: Research from numerous fields of science is providing strong evidence demonstrating that the conditions young children live within mould their health and developmental trajectories.  While science and policy call for nurturing environments to preserve developmental potential, the current global reality is that war and civil unrest displace millions of children from their homes, desecrating their social supports and environments.  Furthermore, little research has drawn attention to the experience of the youngest children during and after war.  Objective: To holistically document the environments of young children (0 to 3 years) before, during and after a 20-year war and mass internal displacement in northern Uganda in order to deepen current understandings, address research gaps and inform interventions. Methods: This applied ethnography used purposive sampling in three sites of the Amuru District over a one-year period.  Interviews, focus groups, longitudinal case studies, participant observation, document review, and photo documentation with young children, caregivers (siblings, parents, and others) and community leaders explored multiple views on early childhood health and development. Results: War and displacement seriously thwarted caregivers from employing their extensive knowledge and traditional care practices that protected and nurtured their young children in rural agrarian communities. Young children were exposed to numerous, cumulative factors that previous research has documented as risks to well-being and long- term developmental potential. This risk persisted well into post-conflict resettlement. However, despite dire conditions, there were also factors that acted to protect children and examples of children’s healthy functioning. Conclusions: Disrupted social structures and environments appear to influence young children's health and developmental futures in all phases of war, displacement and resettlement. Results suggest that the efforts by state and the international community to mitigate risk and promote positive development for vulnerable young children were insufficient and incommensurate with the degree of evidence supporting the critical importance of the early years.  Future efforts must build on local culture and address the most relevant and pressing needs of children in close collaboration with families and communities. The rebuilding of healthy, peaceful societies depends upon the preservation of the immense human capital and boundless potential within children. iii  Preface This thesis is based on work conducted in communities of the Amuru District of Northern Uganda. With the guidance of my doctoral supervisors (Catherine Backman, Richard Mathias, University of British Columbia, Canada), and Herbert Muyinda (Makerere University, Uganda), the members of my doctoral committee  (Robert Armstrong, Charles Larson and Patricia Spittal), and input from the Child Health and Development Centre Faculty (Makerere University), I was responsible for planning the data collection and designing all interview guides. In the field in Northern Uganda Stella Atim (Research Assistant) collected all oral data in the local language (Luo).  I conducted interviews that could be done in English along with the observation of young children in camps and villages. I supervised all data collection, reviewed all translated data, and lead discussions on emergent themes throughout data collection.  Ketty Akello Otim, Samuel Lakor and Lucy Apio contributed to the transcription and translation of research transcripts - assisting Stella Atim.  I conducted all primary analysis checking in with Catherine Backman and Patricia Spittal to confirm emerging themes.  I wrote this thesis manuscript in its entirety. Portions of this thesis from chapters 1, 2, 5 and 7 have been published in the International Journal of Pediatrics under the title “Risks to early childhood health and development in the post conflict transition of northern Uganda” manuscript #820290.  I wrote this manuscript as first author, with contributions from fellow authors Stella Atim, Charles P. Larson and Robert W. Armstrong.  This is an Open Access Journal and thus I retain the copyright of this work, released under a "Creative Commons Attribution License," enabling the unrestricted use, distribution, and reproduction of an article in any medium, provided that the original work is properly cited.  This research received approval from the University of British Columbia, Behavioural Research Ethics Board (Reference number H09-00300) on March 17, 2009.  Approval was also granted from the Uganda National Council of Science and Technology on June 23, 2009 (Reference number SS2214) and the Republic of Uganda Office of the President on June 15, 2009 (Reference number ADM 154/212/01). iv  Table of contents Abstract ..............................................................................................................................ii Preface...............................................................................................................................iii Table of contents ..............................................................................................................iv List of tables......................................................................................................................ix List of figures .....................................................................................................................x List of excerpts from field journals..................................................................................xi List of abbreviations ........................................................................................................xii Glossary of Luo (Lwo) words and local usage of English words ................................xiii Acknowledgements ........................................................................................................xiv Dedication ......................................................................................................................xvii Chapter 1: Introduction and literature review ..................................................................1 1.1 War, displacement and children ...............................................................................1 1.2 Early childhood: setting the stage for the life course ................................................3 1.2.1 The biological basis of developmental outcomes ..........................................4 1.2.2 Risk and outcomes .......................................................................................5 1.2.3 The impact of context and culture on development .......................................9 1.2.4 Protective factors and positive adaptation ...................................................10 1.3 Northern Uganda: war, displacement and its aftermath..........................................12 1.3.1 A brief introduction to Acholi history and culture:.........................................12 1.3.2 The experience of war and displacement ....................................................15 1.3.3 The aftermath of war and displacement ......................................................18 1.4 Conceptual model ..................................................................................................19 1.5 Research question and study objectives ................................................................21 1.5.1 Research question ......................................................................................21 1.5.2 General objective ........................................................................................21 1.5.3 Specific objectives ......................................................................................22 Chapter 2: Methods..........................................................................................................23 2.1 Synopsis ................................................................................................................23 2.2 Guiding methodology and conceptualizations ........................................................23 v  2.3 Sampling................................................................................................................24 2.3.1 Population and site selection.......................................................................24 Pabo Sub County ....................................................................................25 Omee II camp and surrounding villages in Amuru Sub County................26 The villages of Anaka Sub County ..........................................................28 2.3.2 Participant selection....................................................................................28 2.4 Ethics.....................................................................................................................32 2.4.1 Permissions, introductions and recruitment of participants..........................33 2.5 The research team: background, training and team processes ..............................34 2.6 Fieldwork timeline ..................................................................................................35 2.7 Data collection approach and methods ..................................................................36 2.7.1 Semi structured interviews with primary female caregivers .........................37 2.7.2 Focus group discussions (FGDs) ................................................................38 2.7.3 Case studies ...............................................................................................40 2.7.4 Participant observation and photo documentation.......................................41 2.7.5 Regional and community leader interviews or FGDs...................................42 2.7.6 Document review ........................................................................................43 2.8 Translation process................................................................................................43 2.9 Analysis .................................................................................................................44 2.9.1 On- going analysis during data collection ....................................................44 2.9.2 Analysis following data collection ................................................................45 2.9.3 Interpretation...............................................................................................46 2.10 Feedback and knowledge translation .....................................................................46 Chapter 3: The impact of war and displacement on traditional physical protection strategies employed with young children ......................................................................48 3.1 Synopsis ................................................................................................................48 3.2 Findings .................................................................................................................48 3.2.1 Structuring the daily living environment for young children..........................48 3.2.2 The Acholi village:  Protection through place, space and peace..................49 3.2.3 War and displacement: The loss of protection, place, and the emergence of violence and chaos.....................................................................................................50 3.2.4 Food and nurturance in early childhood ......................................................53 3.2.5 Food security and protection against hunger in the village ..........................54 3.2.6 Food insecurity and hunger during war and displacement...........................56 vi  3.2.7 Health knowledge, beliefs and practices .....................................................61 3.2.8 Health in the village.....................................................................................61 3.2.9 Health in displacement camps during war ...................................................64 Chapter 4: The impact of war and displacement on traditional social protection strategies employed with young children. .....................................................................68 4.1 Synopsis ................................................................................................................68 4.2 Findings .................................................................................................................68 4.2.1 The ambient social environment and a young child’s relationships .............68 The ambient social environment of early childhood .................................68 A young child’s relationships ...................................................................69 4.2.2 The social structure of the village................................................................70 4.2.3 Loss of the nurturing social environment/ breakdown of relations and supportive social structures in war and displacement .................................................72 Social breakdown and kin lost .................................................................72 More young children................................................................................73 An atmosphere of discord and violence...................................................74 Alcohol abuse .........................................................................................76 Divorce, separation, and parental abandonment .....................................78 Survival-based neglect of children and a lack of care options .................79 Culture shift to “mine first” .......................................................................82 Caregiver stress and trauma ...................................................................83 4.2.4 Teaching and mentoring young children .....................................................83 4.2.5 Teaching and mentoring in the village.........................................................85 4.2.6 Teaching and mentoring during war and displacement ...............................89 Teachings, traditions and culture lost ......................................................89 Shift in the source of social teachings .....................................................90 The new teachers of Acholi children: strangers, peers, and media..........91 Lost control and child rights.....................................................................92 Positive teaching acquired in camps .......................................................93 Chapter 5: Risks to early childhood health and development in the post conflict transition of northern Uganda.........................................................................................95 5.1 Synopsis ................................................................................................................95 5.2 Findings .................................................................................................................95 vii  5.2.1 The physical environment and process of transition....................................95 Focus on rebuilding.................................................................................95 Without land and support ........................................................................96 5.2.2 The socioeconomic environment of children in post conflict ........................97 The cessation of wartime subsistence.....................................................97 The origins and experience of poverty after war......................................98 Children’s basic needs go unmet ............................................................99 Hard work, poverty reduction approaches and persistence ...................101 5.2.3 Social (care-giving) environment of children in post conflict ......................101 Survival-based neglect ..........................................................................102 The vulnerability of children without parental care and provisions .........103 Social protection offered by the village ..................................................105 5.2.4 The regional resource and service environment of children in post-conflict106 Lack of services in return sites ..............................................................106 Problems with targeting and implementation of services .......................107 Chapter 6: Adaptation and protective factors in a war zone.......................................109 6.1 Synopsis .............................................................................................................. 109 6.2 Findings ............................................................................................................... 109 6.3 Children as active agents of their own adaptation ................................................ 111 Active learning ......................................................................................112 Play.......................................................................................................113 6.3.2 The role of family in promoting young children’s positive adaptation and resilience .................................................................................................................116 Labouring to meet basic needs .............................................................118 Love, attention and responsive care......................................................119 Goals and hope for the future................................................................121 Child-to-child caretaking........................................................................122 6.3.3 Community factors that contribute to children’s resilience .........................126 Communal culture and social support ...................................................127 Access to services ................................................................................128 Spirituality and religion ..........................................................................130 6.4 Okello at the end of our year together .................................................................. 131  viii  Chapter 7: Discussion ...................................................................................................133 7.1 The story behind the thesis .................................................................................. 133 7.2 Synopsis .............................................................................................................. 134 7.3 Thread 1: War and displacement are highly damaging social determinants that threaten young children’s health and developmental potential...................................... 136 7.3.1 Traditional protection strategies thwarted..................................................136 7.3.2 A gap in protection strategies that cannot be filled ....................................137 7.3.3 The accumulation of risk ...........................................................................138 7.4 Thread 2: The cessation of hostilities and formal end of displacement leads to a difficult and prolonged transition phase in which risks persist ....................................... 140 7.5 Thread 3: Protective factors and healthy functioning existed amongst the very difficult circumstances of war, displacement and recovery ........................................... 141 7.6 Thread 4: Efforts to address early childhood in war and displacement were insufficient and incommensurate with the degree of available scientific evidence documenting the critical importance of early childhood................................................. 145 7.6.1 Making the science match the intervention................................................149 7.7 Directions for future research............................................................................... 150 7.8 Comment on strengths and limitations of thesis research .................................... 150 7.8.1 Limitations.................................................................................................150 7.8.2 Strengths ..................................................................................................151 7.9 Conclusion........................................................................................................... 153 References .....................................................................................................................154 Appendix: Case study- Akot .........................................................................................167  ix  List of tables  Table 1: Demographics of caregiver respondents..........................................................30 Table 2: Description of case studies ...............................................................................31 Table 3: Demographics of leaders ...................................................................................32 Table 4: Phases of post conflict transition......................................................................37 Table 5: Sample guiding questions .................................................................................39  x  List of figures  Figure 1: TEAM-ECD schematic.......................................................................................20 Figure 1: Pictures depicting fieldwork team ...................................................................27 Figure 2: Data collection timeline ....................................................................................36 Figure 3: 3-year-old girl practices using and carrying a hoe. ........................................87 Figure 4: The toys of young children.............................................................................114 Figure 5: The pretend play of Acholi children...............................................................116 Figure 6: An illustration of risk and protective factors experienced during and war and displacement ...................................................................................................................135 Figure 7:  Changes in risk and protection from peace to war......................................137   xi  List of excerpts from field journals  Field journal notes 1:  The day we met Okello ..............................................................110 Field journal notes 2: Excerpts about play and active learning...................................111 Field journal notes 3: Okello’s mom talks about how children play in their first three years ................................................................................................................................115 Field journal notes 4: Excerpts highlighting the role of family in Okello’s life ...........116 Field journal notes 5: Mom relays her goals for Okello’s future..................................121 Field journal notes 6: Excerpts about Okello’s development and the role of lapidi...125 Field journal notes 7: Excerpts about the role of neighbours in Okello’s life ............127 Field journal notes 8: Excerpts about services accessed for Okello ..........................128 Field journal notes 9: Mom talks about her battle with mental illness and the role of religion.............................................................................................................................130  xii  List of abbreviations  CPC  Child Protection Committees ECD  Early Childhood Development FGD  Focus group discussion GoU  Government of Uganda LC  Local Council Leaders (Grassroots government officials) LRA  Lord’s Resistance Army NGO  Non-governmental organization NRC  Norwegian Refugee Council NRM  National Resistance Movement PRDP  Peace, Recovery and Development Plan TBA  Traditional Birth Attendant UNFAO The Food and Agriculture Organization of the United Nations UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund VHT  Village health Teams WFP  World Food Program      xiii  Glossary of Luo (Lwo) words and local usage of English words Acholiland The districts in northern Uganda predominantly composed of ethnic Acholi persons. Awaa! A sound made for a child meaning danger. Bol Chup Group savings and loans scheme started during camp living. Bush (The bush) Rebel encampments were described as the bush.  When rebel forces abducted someone, they were often described as being taken to the bush. Dayo Grandmother Dig/ Digging Cultivation, agricultural pursuits Garden Agricultural land Juka Rural village.  Juka means ‘to stop’ and this term came into usage during the war when the village became a place people were stopped from going. Koko! A sound made for a child meaning ‘bites!’ (i.e., biting insects, dogs) Kony Rebel fighters (Named after the current leader of the rebels, Joseph Kony) Lakwena Rebel fighters (Named after the former leader of the rebels, Alice Lakwena) Lapidi Child babysitter (can be sibling, relative or other). Ongon Lignums that were laid down in the past by elders to regulate public life- codes or prescriptions of how to handle situations, etc. Paste A type of traditional Acholi sauce made with groundnuts or sesame that coats a main dish such as green vegetables, starches or meat. Considered to be highly nutritious. Produce Give birth to. Rwot Kweri A traditional male chief generally selected because of high achievement in agricultural pursuits; a leader in productivity who organizes and leads a village. Rwot Okoro A traditional female chief who organizes and mobilizes the women for agricultural activities such as weeding or other communal pursuits. Te-te Baby talk for “stand, stand” used to encourage a child to stand and take steps. Tin An empty container such as a water bottle or Vaseline container that children use as toys for playing. Wangoo Nightly campfire with family members. xiv  Acknowledgements I extend sincere gratitude to all those who made this research possible and helped me to shed light on the lives of young children impacted by conflict and displacement.  Firstly, I thank the participants of this study who opened their homes, their communities and their lives to this research for the sake of children.  In particular I want to acknowledge with deep gratitude the 6 families who became case studies and shared a year of their lives with us. Their insights and experiences were invaluable to this work and I continue to think of them with affection and to be awed by their strength and spirit.  I am especially grateful to Stella Atim, my partner in this data collection.  Stella embraced this research with her whole heart and worked tirelessly to arrange logistics, share her vast insight and knowledge and successfully collect and translate this data from the local language of Luo.  Her integrity and passion was the backbone of this work and I continue to cherish the friendship that developed between us.  I also thank Ketty Akello Otim, Samuel Lakor and Lucy Apio who skillfully did translations on the work as well as providing thoughts and insight on the emerging data.  David Ojok and Martin Ochieng deserve gratitude for always ensuring we got safely to the field and home, and assisted in whatever capacity was required. A better team of people I could not have dreamed of and I am grateful to have had the time with them to share this work and our lives.  Special gratitude goes to Catherine Backman, who was my touchstone throughout this doctoral journey.  Her assured guidance, knowledge, attention to detail and willingness to offer support and answer my many questions meant I could always trust that I was not too far off track.  Her diligent reviews and practical feedback contributed substantively to the final form of this thesis.  Sincere thanks goes to Herbert Muyinda who provided encouragement, supervision technical guidance to me during my year and a half in Uganda and beyond.  Always generous with his time, Herbert challenged my thought process, provided concrete guidance and assurance.  He also arranged for me to present my ‘work in progress’ to his skilled and knowledgeable professional colleagues at the Makerere Child Health and Development Centre (CHDC) whose feedback was invaluable.  I cannot leave unnamed Augustine Mutumba, the CHDC Administrator who expertly guided me in navigating the administrative requirements to get the research up and running.  I owe deep gratitude to Patricia Spittal who whole-heartedly embraced the vision for this research and made it reality through her knowledge, Ugandan contacts, and encouragement.  She was always willing to go beyond the academics, to emotionally xv  support and inspire me to strive for balance and achievement in both my professional and personal lives. She continues to provide me with opportunities to grow and learn.  I am very grateful to Richard Mathias who opened the doors to my career in global health back in 2005 and has been a constant supportive presence since this time. His ideas and feedback from the early days were helped in focusing this thesis. He has guided me in navigating the unfamiliar territory of academics and assured me I would complete doctoral work many years before I admitted it to myself.  My gratitude is also extended to Charles Larson for his critical eye and willingness to challenge with constructive feedback and questions.  His insights improved my writing and thinking and increased my awareness of alternate viewpoints.  I am especially indebted to Bob Armstrong for believing in me throughout the years. He has provided me with many opportunities to grow and prove myself both professionally and academically.  Gratitude is owed to the Canadian Child Clinician Scientist Training Program, the Centre for International Child Health at BC Children’s Hospital and the Child and Family Research Institute who supported me financially to conduct this research, but also provided education and guidance that allowed me to grow as a professional.  This research was also made possible by the generous operational funding from the International Development Research Centre and the Human Early Learning Partnership at the University of British Columbia.  Sincere thanks goes to Lori Irwin, whose presentation on her work for the WHO early childhood knowledge network re-ignited my passion to work with young children and changed the direction of this research focusing it on early childhood.  Further, presentation and discussion with her other colleagues at the Human Early Learning Partnership crystallized this work during its conception.  I acknowledge with thanks, Gayle Ginsburg, editor extraordinaire who helped clean up this thesis, improved the flow and gave just the encouragement I needed in the final hours.  I want to acknowledge with gratitude Jessica Hubner and Hayden Aaronsen for listening to my appeal in regards to the importance of early childhood and for turning this research into action. To USAID SPRING and AVSI for taking up the challenge to meet the needs of young children through their early childhood care project and to WACFO and CPA for rolling it out in communities- your dedication and commitment was truly inspiring.  As well, Kisembo Mattias, the Community Development Officer for the Amuru District deserves xvi  recognition and gratitude for his vision, forthrightness and action.  To Ongom Santos Gibolo, Former Protection Officer for (NRC) and the nurses and doctors of Lacor hospital for their compassionate care of children who we brought to them in desperate condition.  To Hillel Goelman, John Beatty and Janice Matautia of the Interdisciplinary Studies Graduate Program at UBC, I send my thanks for the many ways you have encouraged and supported me throughout my time in the program.  To Kyle Matsuba I owe gratitude for his insights, encouragement, editing advice and guidance both at home and abroad.  Bouncing ideas around with Kyle was essential to focusing my thinking.  Thanks go to Laura Lee, Lara Rosenoff, Letha Victor, Mineko Wada and Sandra Hale, fellow students who were always willing to engage in discussion, share ideas and materials, read drafts and pursue joint presentations. Engagement with these individuals added to this thesis in multiple ways.  While in Uganda I was fortunate enough to develop friendships with a group of wonderful people who enriched my life and work, in particular I would like to thank Saad Karim, Melissa Adams, Roberta Romano, Jeanne Briggs, Sarah Toner and Erin Majesty.  Over to Oz, my appreciation goes to Karen Wlasichuk for being my chief cheerleader, first line editor and most importantly, a life-long friend who has seen me through everything life delivers.  Back in Canada, I want to give gratitude for Joyce Lam, Karen Davies, Christine Kariatsumari, Terry Ho, Diane Wickenheiser, Ronnie Gill, Louisa Pulfrey, Jen Gellis, Amber Murray, Alan Cheung and the many other amazing friends who have put up with my long absences over the years, supported and encouraged me and always made me feel like I never left.  Finally, I am forever indebted to my family who believed in me the times when I faltered believing in myself.  To my husband Daniel Dirscherl who buoyed me through the stress and separation and who was my driver, tech guy, proofreader, accountant and far most importantly my love.  To my dad Robert McElroy who always supported me in any and every way he could, told me to just do my best and took pride in my accomplishments.   To my mom, Monica Marcoux who talked me down to earth when I got lost elsewhere and believed in me the whole way.  To Sofka and George Dirscherl, my very supportive in-laws who helped me establish a home back home and provided the loving childcare that enabled me to see this journey through to its conclusion.  To Nana for her daily comfort and unconditional love - coming home to her from the field always made a hard day better.   And to my son Ethan, who came along at the end of this journey and changed my life forever.   xvii  Dedication I dedicate this work to six very special children who touched my heart: Brenda, Nancy, Kevin, Michael, Achen and Opio. They have endured too much in their short lives and yet their joy and unstoppable spirits shine through and give everyone hope for a better future. And I dedicate this work to my son Ethan who made me understand how deeply their mothers love them.  1 Chapter 1: Introduction and literature review The rapidity and sensitivity of early brain development makes early childhood the most critical period in the human lifespan. Consequently the conditions experienced in the earliest years of life can have profound and enduring impact on future health and developmental trajectories (Center on the Developing Child at Harvard University 2010; ECDKN 2007a; Engle et al., 2007, 2011; Grantham-McGregor et al., 2007; Hertzman et al., 2010; Margolin & Gordis, 2000; Meaney, 2010; National Scientific Council on the Developing Child, 2007; Shonkoff, Boyce & McEwen, 2009; Szyf 2009; Walker et al., 2007, 2011; Young & Mustard, 2008).  When children do not experience nurturing environments there can be repercussions not only for the development of the individual but the development of sustainable, peaceful and equitable societies (ECDKN, 2007a). Yet all too often young children are exposed to conditions that do not meet their most basic needs for health and development.  War is one such condition.  This thesis presents a case study of war and displacement as social determinants of health and development for young children in Northern Uganda.  This first chapter introduces the reader to the general context of children who live in conditions of war and displacement and highlights why early childhood is such a vital phase in human development.  Further, it provides background information about the history and context of Northern Uganda, and outlines the research objectives of the study.  1.1 War, displacement and children There are approximately 26 million internally displaced people globally.  These are people who remain within their own countries but have been forced to leave their homes due to violent conflict, violations of human rights and/or generalized violence (UNHCR, 2008). The African continent, the region most impacted by internal displacement, has an estimated population of 11.6 million displaced people, approximately half of who are children (UNHCR, 2008). These children are away from their home environments and without the social supports that typically provide routine and nurturance during the most critical stages of their development.  Displacement often occurs as a result of conflict.   Throughout the world there are currently more than 1.5 billion people living in countries which are experiencing violent conflict (World Bank, 2011).  While there is debate over the veracity of wide-sweeping claims that 90% of  2 modern casualties of war are civilians, data suggest that there are indeed high rates of civilian casualty in modern wars on the African continent, including Northern Uganda (Roberts, 2010).  The toll on life and well-being is great when both the direct and indirect consequences of war are taken into account: combat violence and landmines are examples of the former, while the latter include mass population displacements; lost property; lost livelihoods; poverty; high disease rates and weak health systems; food insecurity/ under- nutrition; social collapse; psychological wounds; strained governments and political dysfunction; and increased violence and criminality (Roberts, 2010; Wessells & Edgerton, 2008).  Violent conflict therefore has a profound impact on the development of both people and countries (World Bank, 2011).  A growing body of literature and research is highlighting the experience of children and youth living in conditions of violent conflict and displacement. The knowledge put forth has illustrated how children are deeply and holistically affected by violence; the loss of, or separation from family members; caregivers who are themselves overwhelmed; the breakdown of social networks; disease; economic devastation; the destruction of basic infrastructures; and the loss of opportunities considered necessary for healthy development and well-being, such as education and training in the skills needed to earn a livelihood (Boothby, Strang & Wessells, 2006; Chatty, Crivello, Lewando & Hunt, 2005; Boyden & de Berry, 2004; Machel, 2001; Wessells & Edgerton, 2008; Wessells & Monteiro, 2008).  The risk that accumulates in such situations seriously threatens developmental outcomes (Wessells & Edgerton, 2008). At the same time, this body of work also highlights children’s resilience. As Boyden and de Berry (2004) explain: “…while it is difficult to exaggerate the horrors of war, it is quite possible to overuse concepts such as trauma.  Young people’s responses to war are revealed as multifaceted and nuanced; age is not necessarily the critical determinant of vulnerability, and even when profoundly distressed or troubled, the young frequently exercise remarkable resilience” (p. xvii).  This focus on resilience leads to the identification of factors that contribute to positive outcomes, such as unification with family, provision of culturally appropriate interventions, and promotion/maintenance of healthy daily routines such as education (Boothby, Strang & Wessells, 2006). Furthermore, it guides future research and action by stressing the importance of a balanced consideration of both risk and protection.  However, most of the research in this field highlights the experiences of older children in  3 war, not the experiences of the very young and highly dependent, who essentially have no voice (Fonseca et al., 2008; Walker et al., 2007). Exceptions include surveys of mortality, health and nutrition, which specifically target children under five and acknowledge their physical vulnerability (O’Hare & Southall, 2007; The Republic of Uganda Ministry of Health, WHO et. al., 2005).  Additionally, studies conducted for the implementation of aid and development programs (Jones, 2007; Wessells & Monteiro, 2008; Kostelny & Wessells, 2008) provide valuable insights into local child rearing practices, elucidate the social- ecological contexts of early childhoods lived during war, outline children’s needs as well as the risks they face, and suggest interventions that promote well-being. Wessells and Monteiro’s (2008) ethnographic research in Angola concluded, “a high priority for the early childhood development (ECD) field is to extend its concept and practice to war zones” (p. 319).  Wessells and Edgerton (2008) acknowledge that the very youngest are amongst the most vulnerable in war, especially when caregivers become overwhelmed or prevented from providing effective care.  These types of research emphasize the need to focus on ecological approaches that encompass the multiple levels of influence on children (i.e. family, peers, and community). At the same time – and in light of documented evidence regarding the key role which early childhood plays in shaping an individual’s life course (see section 1.2) – there is a clear scarcity of research that seeks a holistic understanding of the factors that affect infants and very young children in such complex and potentially high-risk environments (Walker et al, 2007). This research aims to address that gap.  1.2 Early childhood: setting the stage for the life course Early childhood is a critical period of human development that sets the stage for learning, behaviour, social relations, and mental and physical health throughout the lifespan. The first three years of a child’s life are particularly critical because they are a time of rapid brain growth, during which young brain cells differentiate/specialize and connect through the stimuli of seeing, hearing, touching, moving, exploring, and being cared for and responded to (Grantham-McGregor et al., 2007). As a child’s development is based on their personal experiences, the physical and social-cultural environments sculpt the emerging structure and function of the brain and body (ECDKN, 2007a; Young & Mustard 2008). The positive stimulation received in responsive and nurturing relationships, exposure to safe, supportive environments, and having physical needs such as adequate nutrition (Center on the  4 Developing Child at Harvard University, 2010; ECDKN, 2007a) facilitate “the ordered emergence of interdependent skills of sensori-motor, cognitive-language, and social- emotional functioning” (Engle, 2007, p.229). If children develop to their potential, they are well positioned to become healthy adults with the many competencies necessary to contribute to their own well-being as well as that of their families and societies (Center on the Developing Child at Harvard University, 2010; ECDKN, 2007; Hertzman et al. 2010).  1.2.1 The biological basis of developmental outcomes Fields such as developmental psychobiology, neuroscience, genomics and epigenomics, have revolutionized our understanding of the mechanisms by which early experiences affect life-long development. Researchers have proposed two means (at least) by which risk alters outcomes: the cumulative harm of experienced adversity across time, and biological mechanisms that embed adverse experiences at sensitive developmental points (Kuh & Ben-Shiomo, 2004 and Keating & Hertzman, 1999 in Shonkoff et al., 2009).  Current research reveals that the contexts in which children live and the experiences they have interact with their genes through a chemical process called epigenetics, to chemically imprint the child’s genome structure (Meaney, 2010; National Scientific Council on the Developing Child, 2010). Regardless of whether the chemical imprints are transient or permanent, they alter the ease with which genes can be turned off or on.  This in turn impacts the genes’ short or long-term expression and the genomic alternations can be passed on to future generations (National Scientific Council on the Developing Child, 2010). For example, if a child has recurring adverse experiences of high stress and/or malnutrition, it can leave epigenetic markings on particular gene sets which change the functioning of the brain and other critical organ systems, thereby altering how the child responds to adversity in the long term (Szyf, 2009; National Scientific Council on the Developing Child, 2010). This can increase the risk of poor physical, cognitive, and/or social-emotional outcomes.  The same epigenetic mechanisms act when a child has positive experiences. If a child has exposure to nurturing, stimulating environments it can lead to epigenetic changes that provide a basis for successful learning and interaction in the future (National Scientific Council on the Developing Child, 2010). Certain genes can only be altered during specific periods of early development, while other epigenetic changes can occur across the lifespan (National Council on the Developing Child, 2010). This plasticity suggests that even though  5 epigenetic changes can last across the lifetime, they have the potential for reversibility through intervention therapies or drug treatment. However, the investigation of which interventions would achieve such reversibility is an area of research requiring further study (Szyf, 2009). This biological basis of early childhood development is central to the rationale for studying the environments in which young children live, and identifying factors that influence developmental outcomes.  1.2.2 Risk and outcomes The literature conservatively estimates that worldwide more than 200 million children who are under the age of five, and live in low-income countries (such as Uganda) fail to reach their developmental potential (Grantham-McGregor et al., 2007). Research demonstrates that a number of significant risk factors can undermine these children’s development, including poverty, malnutrition, poor health (infectious diseases such as malaria), and psychosocial factors (excessive stress, exposure to societal violence, maternal depression, a lack of stimulation, and inadequate social interaction in the home environment) (Grantham-McGregor et. al, 2007; Walker et al, 2007, 2011).  Poverty: The socioeconomic environment is a pervasive and fundamental determinant of early childhood development and an inequitable distribution of socioeconomic resources results in inequities in early child development both in and between societies (ECDKN, 2007a; Hertzman et al., 2010). A ubiquitous gradient effect exists such that every degree of improvement in socioeconomic status translates into a correspondent prospect for improved child development outcomes (ECDKN, 2007a; Hertzman et al., 2010). This is due to the fact that children of lower socioeconomic status are more likely to live in environments, and have experiences, which are less nurturing.  A number of studies have demonstrated that children living in poverty with conditions such as inadequate food and poor hygiene and sanitation have an increased risk of adverse experiences such as infection and stunting (reduced height for age) (ECDKNa, 2007; Grantham- McGregor et al., 2007). Mothers living in poverty have been found to have lower levels of education, higher levels of stress, and are at higher risk of depression (Shonkoff & Phillips, 2000 in ECDKN 2007a).  Poverty has also been associated with lower levels of stimulation for children. In an analysis of cross-sectional and longitudinal studies from developing countries, children living in poverty consistently demonstrated substantial development deficits when compared to children who lived in circumstances of greater affluence (Grantham-McGregor et al., 2007).  However, poverty is  6 not a life sentence.  A study conducted by Willms (2002) showed that there were no socioeconomic gradient effects in cognition and behavioural outcomes when children experienced quality interactions such as having good social support or being read to regularly (Young & Mustard, 2008).  Malnutrition: Research has consistently associated moderate or severe stunting due to malnutrition with lower cognitive and educational achievement (Grantham-McGregor et al., 2007, Walker et al. 2007, 2011). As noted by Alderman and Engle (2008), malnutrition impacts the development of cognition in two ways: firstly, children who are malnourished are less likely to interact with/seek out stimulation from caregivers and their environment, which limits their learning; and secondly, malnourished children may have a diminished capacity to learn because of the impact of the lack of nutrients on the brain. Micro nutrient deficiency can also have long-term impacts.  For instance, numerous studies on iron-deficiency anaemia in infants have shown short-term impacts on neurophysiologic, mental, motor, and social-emotional functioning and there is consistent evidence demonstrating that developmental risks may persist despite even when the deficient infants receive iron supplementation (Walker et al., 2007, 2011).  Disease: Infectious diseases such as HIV/AIDS, diarrhoea and malaria can also impact child development and outcomes in different ways.  Firstly, organisms that infect the brain can directly cause focalized or extensive damage leading to neurological impairment.  Nutritional status and growth can be impacted through a loss of appetite and/or alterations in the body’s capacity to retain and absorb nutrients.  Furthermore, infectious diseases, particularly when they occur repeatedly, can decrease the exploration or stimulation seeking behaviours needed for healthy development. In Sub Saharan Africa, malaria is responsible for up to 40% of the paediatric admissions to health facilities (Walker et al., 2007) and new studies are linking repeated malarial attacks to functional outcomes such as lower scores on tests of cognition, grade repetition and lowered primary school completion rates (Walker et al, 2011). Lastly, when caregivers acquire serious infectious diseases such as HIV, children’s risks for poverty, orphan hood, abandonment and disrupted care-giving increases (Walker et al, 2011).  Lack of stimulation and interaction: Young children need positive interactions as well as age- appropriate sensory (i.e. object play) and social-emotional (e.g. attentive, responsive care  7 giving) experiences to stimulate healthy brain development.  These experiences affect particular circuits in the brain during developmental stages or “sensitive periods” and neurological processes build upon each other as they become more sophisticated (ECDKN, 2007a; Glaser, 2000; National Scientific Council on the Developing Child, 2007). The sophistication of sensory and social emotional experiences therefore needs to increase as children mature in order for them to fulfill their developmental potential (ECDKN, 2007a; National Scientific Council on the Developing Child, 2007).  Children who are deprived of age-appropriate experiences and who experience adversity are less likely to fulfill their potential. As documented in the literature, childrearing necessarily focuses on protection and survival in extremely stressful circumstances such as severe poverty, food/water insecurity, disease epidemics, and wars/conflict.  In such circumstance, caregivers under great pressure from lack of resources, too many responsibilities, or their own compromised mental and/or physical health can be rendered unable to be fully responsive to children’s behaviour (Evans, Matola & Nyeko, 2008).  Studies of children raised in developing country orphanages who were later adopted into nurturing families dramatically demonstrate the neural damaged caused by stimulatory deprivation.  The damage increases in relation to the length of the deprivation, concurrently increasing the likelihood of long-term impacts.  This occurs even when the children are adopted into nurturing families.  The earlier the age of adoption, the better the long-term outcomes in terms of intelligence, school performance and behavioural measures (Engle et al., 2007; Noble, Tottenham & Casey, 2005; Young & Mustard, 2008, Walker et. al., 2011).  Although the brain remains flexible (or plastic) to new learning and/or remediation throughout the life course, neural processes which are easily acquired through appropriate stimulation in the early years are much more difficult to develop or correct later in life.  In other words, it takes considerably more effort, resources, and time for an adult to develop neural processes that come naturally to a child in typical, nurturing conditions (National Scientific Council on the Developing Child, 2007).  Exposure to violence: Global statistics on homicide and child abuse suggest that children aged 0 to 4 are most at risk for experiencing violence; more than twice as likely as older children age 5-14 years (Bissell, Heissler, Keane & Ulkuer, 2011). High levels of stress can  8 escalate violence within families (Fonseca, O’Gara, Sussman & Williamson, 2008) and have profound impacts on children both in the present and future. In the most severe cases, violence can lead to the young child’s physical impairment and even death.  Evidence is also mounting to demonstrate that childhood exposure to violence is associated with altered mental and physical health; delays or regressions in developmental attainment; impaired social relations; limitations to learning and academic achievements; behavioural disorders (i.e. aggression, delinquency); emotional disorders (i.e. depression, anxiety, post-traumatic stress); altered worldviews; and impeded moral development.  Exposure to serious violence at a very young age has long-term repercussions and can inhibit children’s future development into healthy, peaceful adults (Fox & Shonkoff, 2011; Glaser, 2000; Margolin & Gordis, 2000; UNICEF, 2006).  A new study of violence conducted in six countries around the world, (one being Rwanda, Uganda’s neighboring country) has shown that when male children witness violence, they are significantly more likely to become men who commit violent acts (Contreras, Singh, Heilman, Barker & Verma, 2011).  Research that aims to explain such associations has begun to demonstrate that the experience of fear and chronic stress can adversely alter the growth and functioning of the brain, particularly in the amygdala, the hippocampus and the prefrontal cortex (Fox & Shonkoff, 2011).  Impairments associated with risk factors: If children experience the previously described adverse circumstances, it can cause a broad range of deficits (physical, social-emotional and cognitive) to appear in early childhood, impeding the capacity for developmental processes to build on each other.  Consequently, the deficits can increase in severity across the life span (Grantham-McGregor et al., 2007).  Furthermore, “developmental and biological disruptions during the prenatal period and earliest years of life may result in weakened physiological responses (e.g., in the immune system), vulnerabilities to later impairments in health (e.g., elevated blood pressure), and altered brain architecture (e.g., impaired neural circuits)” (Center on the Developing Child at Harvard University, 2010, p.2).  These disruptions are strongly associated with Attention Deficit Disorder and other psychiatric conditions such as depression, anxiety disorders, as well as physical diseases such as diabetes and heart disease (ECDKN 2007a; Shonkoff et al, 2009; Young & Mustard, 2008).  When children do not reach their developmental potential, they are less likely to stay in  9 school and their academic performance and retention rates drop.  This diminishes their capacity to fulfill their potential and commonly reduces wage-earning prospects later in life (ECDKN, 2007a; Grantham- McGregor et al., 2007; Fonseca et al., 2008; Young & Mustard, 2008). Children of poverty who remain poor throughout their lifespan are likely to have more children than they would otherwise and have a reduced capacity (time, education, resources, skills and knowledge) to promote their children’s health and well-being (i.e. provide good nutrition, access to clean water, safe shelters, health care, educational opportunities and experiences which stimulate appropriate cognitive development) (Garcia, Virata & Dunkelberg, 2008; Grantham- McGregor et al., 2007). This serves to perpetuate the cycle of disadvantage and poverty.  When the lives of a large percentage of a country’s population are bound by this cycle, it impacts that country’s development as collective society (ECDKN, 2007a, Jaramillo et al, 2008).  1.2.3 The impact of context and culture on development From the moment they begin to develop as a fetus, humans are biologically programmed to adapt to the conditions of their environments. Traits that can be protective in one context or in the short term can pose a risk for adverse outcomes in other contexts or in the long term. Research therefore does not – and/or should not – suggest that there is one single correct approach to protecting or nurturing children; rather, context must be considered (Meaney, 2010).  All children share the biological basis for development and progress through ordered development of skills.  Additionally, there are universal survival needs that have to be met for all children, such as the need of food and protection from physical harms and the need for interaction. Nonetheless, while there are commonalities, the conceptualizations and contextual realities of early childhood are also diverse and strongly influenced by culture. Culture is the shared behaviours, knowledge, understandings, practices, social arrangements and beliefs of a group of people  (LeCompte and Schensul, 1999).  People both create cultural processes and are created or shaped by culture (Rogoff, 2003). The field of cultural psychology highlights culture as being the most important system in which development occurs and describes development as a process of growth into a culture or into the social role of group member (Lee & Walsh, 2001 in Lee & Johnson, 2007).  Care-giving roles, beliefs, morals, practices and knowledge about child rearing vary among cultures, as do the holistic environments that shape young children and determine which life outcomes  10 are desirable and actualized (Kostelny, 2006; Boyden & Mann, 2005; Lee & Johnson, 2007; Nsamenang, 2008). In diverse cultures and contexts around the world, children develop and thrive, and “what is adaptive in child development is very much a product of these specific settings” (Dawes & Donald, 1994 in Boyden & Mann, 2005, p. 17).  Research and programming on early childhood must recognize divergent cultural ideologies that impact childrearing practices (Cabanero-Vervosa & Elaheebocua, 2008; LeVine, 2004; Nsamenang, 2008). For instance, research conducted in non-Western cultures has disputed the commonly held view that the child-mother relationship is supreme in terms of providing a blueprint for children’s social emotional development. The singular child-mother relationship is less fundamental in cultures that routinely employ communal care-giving practices, such as having older-children care for infants (Harkness and Super, 1992; Mann, 2004; Weisner, 1977). There is evidence that young children form strong and healthy attachments with other adults such as grandmothers, stepmothers, fathers and sibling caregivers (Ainsworth, 1967) and that older children who care for the younger display nurturing, responsible and pro- social behaviours at an earlier age than children who do not have this opportunity (Aptekar, 1988 and Harkness and Super 1992 and Gegeo 1991 and Weisner, 1984, 1987, 1989 and Whiting & Edwards, 1988 and Whiting & Whiting, 1963 in Mann, 2004). Communal care- giving is thus one example of a practice that varies across cultures, but which evidence has shown can support healthy development.  In aiming to understand the why, what, how and whom of the child’s earliest life experiences it is therefore critical to explore local perspectives on care-giving through a broad ecological lens and with attention to culture and context.  1.2.4 Protective factors and positive adaptation Even in the most stressful of situations, young people’s psychological and emotional health, as much as their development, is heavily mediated by relationships with caregivers, peers and others, by access to services and availability of opportunities (Boyden & de Berry, 2004, p. xv)  There is increasing recognition that it is not only important to study the factors that put children at risk for development impediments and/or negative life outcomes – it is also important to examine the factors that facilitate positive adaptation under adverse circumstances, a dynamic process referred to as “resilience” (Cicchetti, 2010).  11  Research has documented a number of factors that positively reinforce children’s lives and contribute to good outcomes; these are referred to as protective factors.  These supportive factors occur on multiple levels from the individual, to the group/family, to the broader environment.  Looking at the current evidence on individual level factors it is apparent that not all are applicable to children birth to 3 years owing to developmental stage, e.g., critical thinking.  However, some factors are present and/or emerging in these earliest years of life such as having health and strength, possessing certain temperament and coping factors like resourcefulness, curiosity, adaptability, and/or having a drive to help others (Boyden & Mann, 2005).  Beyond inner resources, having close, attentive and responsive relationships with caregivers and family members has been demonstrated to be a critical factor for promoting resilience and mediating risks (Boothby et al, 2006; Boyden & Mann, 2005; Cicchetti, 2010). In early childhood, these relationships enable infants and young children to form healthy emotional and physical bonds with others; a process known as attachment. Dr. Mary Ainsworth, one of the most influential researchers of attachment, studied a Bagandan population in Southwestern Uganda early in her career. She observed that development of attachment or “first love” between a child, his mother and/or important others, is acquired over time in an interactive process between the child and their social environment (Ainsworth, 1967).  Ainsworth stressed the importance of the child’s own actions: “a literal or figurative seeking out, fastening on, holding to, and resisting the severance of the tie” (p. 440) with another human being.   Further, babies in this Ugandan sample who developed secure attachments had mothers (or substitute mothers) who gave “more time, care and attention” than babies who were less securely attached or unattached (Ainsworth, 1967). Ultimately, when children develop healthy attachments, they are able to rely on the caregiver as a safe base from which to explore the environment and over time the child comfortably moves further away from the base attaining self-sufficiency. Thus, attachment supports the child’s development of competence and control (Ainsworth, 1967) and has been associated with positive life outcomes.  For instance, in a 30-year study conducted among a vulnerable population in the USA, it was found that children who were resilient consistently had histories of secure attachment as infants (Sroufe, 2005).    12 In addition to being important for the development of attachment, having a functional, supportive social network may mediate a young and dependent child’s experience of war and displacement, and mitigate the often-extreme challenges of those experiences. Supportive relations can sooth a child, help the child interpret and process disturbing circumstances, as well as provide protection and normalization (Boothby et al., 2006; Boyden & Mann, 2005).  Furthermore, the child’s family or closest social network supports a child by meeting basic needs; providing structure and reliable routines of stimulation, guidance and instruction (which fosters skills and competencies); and serve as an access point to resources in the broader environment, including healthcare, education, and social connections within the community (Ager, 2006, Boothby et al., 2006, Unger 2005).  It is for these reasons that family reunification has been prioritized for children in war zones as a key means to decrease young children’s vulnerability and promote resilience (Boothby et al., 2006).  Finally, scholars such as Boyden & Mann (2005) and Ungar (2005) also direct attention to factors in the broader environment that foster resilience. Communities that are well- resourced, socially equitable, and which provide access to services such as health care and education offer conditions that promote individual well being (Unger, 2005). In low-income countries where state resources may be minimal or non-existent, non-state actors may take on child protection roles, for instance, traditional practitioners, spiritual leaders, and/or community groups engaging in collective activities (pooled labour, labour exchange, advocacy) (Boyden & Mann, 2005).  “Resilience” and “coping” are not fixed states of being (Boyden & Mann, 2005). The factors that promote resilience, and the manifestations of resilience outlined above are contextually and culturally influenced (Ungar, 2005).  Because these factors are changeable throughout the life of an individual, care and attention given to children and the communities in which they live has potential to improve developmental outcomes.  1.3 Northern Uganda: war, displacement and its aftermath 1.3.1 A brief introduction to Acholi history and culture: The Acholi region of northern Uganda lying south of Sudan, and north east of Murchison Falls National Park, is composed primarily of savannah grasslands and forested hills.   The culture and agrarian lifestyle of the Acholi people have evolved throughout centuries of  13 change to regional economics, social-political order, language, education and employment structures. The earliest recorded change in political-social structures in Northern Uganda occurred in the 18th century when the common Acholi identity was evolving.  Prior to this, the region was composed of Central Sudanic, Niolitic and Luo speaking peoples who co-existed relatively independently. The shift towards a common language and social political order (based on lineage villages situated within chiefdoms), occurred primarily as the population vied for survival through droughts, famines, and raids, but also as they sought prosperity through trade and marriage (Atkinson, 1994). By the early to mid-1800s, Arabic traders arriving in the north of Uganda found a large region of peoples with a common language and social-political order, whom they called ‘Shuuli’ which later became ‘Acholi’ (Atkinson, 1994; Girling, 1960).  In the decades that followed, powerful external actors including Arab slave traders, Egyptian government forces (seeking control of the area as part of the Equatoria province), Swahili gunrunners/slave traders from Mombassa, and invading military campaigns from the British Colonizers brought oppression upon the Acholi populace in the form of raiding, looting, destruction, extortion, foreign administration and influence (Girling, 1960; Heron, 1976).  In the early 1900s Acholiland was placed under British colonial governance structure - one of the last Ugandan regions to fall under the rule of the British Protectorate.  The colonial powers did not appreciate or understand traditional Acholi decentralized governance where authority was shared among lineage heads and chiefdoms were inherited.  Hence, the colonial administration favoured the Baganda, a group in the central region of the country, whose monarch structure was familiar and workable (Atkinson, 1994; Girling, 1960). The colonial period did much to entrench the division of Uganda by both region and ethnicity, highlighting difference, favouring certain groups and fostering local prejudices and resentment that haunted the country after independence (Atkinson, 1994; Refugee Law Project, 2004). The colonizers also forced a significant alteration to Acholi culture and social-political organization: for the first time authority positions were not inherited but appointed, wage-earning labour and the market economy was introduced (sometimes by force), and people were relocated to road-accessible regions for easier administration (Atkinson, 1994; Girling, 1960). Under colonialism the Acholi people were a source of cotton cash crops and the men a source of police and military power; they have remained a strong presence in military (and rebellions) ever since (Gersony, 1997; Girling, 1960). Further, alongside the colonial governance, missionaries established an enduring place in the north  14 – introducing formalized mission education and discouraging traditional spiritual practices (Atkinson, 1994; Girling, 1960; Heron, 1976).  Nonetheless, historical records reveal that despite this ambush of influence, the Acholi livelihood and culture endured as it evolved.  Clan ritual was not diminished by missionary influence, but persisted alongside the adoption of Christianity (Russell, 1966 in Heron, 1976). The traditional chief structure in villages, while changed, continued to exist alongside the formal government leadership of Local Council Leaders (LCs).  In addition, the region had (has) an elaborate oral literature passed on through generations and beautifully documented in the works of Acholi scholar Okot p’Bitek.  Acholi proverbs, myths, folk stories, songs and dances, preserved the history and beliefs of a people, conveyed moral messages, demarcated formal ceremony and celebration of clan events (i.e., birth, death, courting), distinguished political occasions and brought pleasure (Heron, 1976; p’Bitek, 1974). Children in growing up in rural villages were embedded in these cultural practices. For instance, stories told in the early evening as the family gathered before the littlest family members went to bed, were kept short and simple and tailored to developmental level of the children (p’Bitek in Heron, 1976).  As p’Bitek (1974) notes, the stories, games and songs for the youngest Acholi children offered an important introduction to moral and cultural education.  Acholiland was also deeply rooted in the social and cultural structures that supported the rural agrarian life. Daily activities centered on physical work completed communally by the extended family. The kin members formed an interdependent social unit, materially and psychologically, which enhanced protection, survival, and well-being (Kagitcibasi, 2005; Greenfield et al., 2003). Adult women carried out much of the domestic and agricultural labor including and taking care of children, planting, weeding, harvesting, collecting water and preparing food (Barrett & Brown, 1993; Barrett, 1997). Adult Acholi males were the traditional heads of family, and as such, were protectors and decision makers (Dolan, 2002). Their livelihood pursuits, which included building structures (homes, latrines, granaries), livestock rearing, heavy agricultural labor i.e. clearing the land for planting, and increasingly, wage-earning labor, provided for and sheltered the family. The ownership of land and livestock supported the masculine role/identity of protector and provider.  The family elders, both male and female, bore and transmitted traditional knowledge; they guided and taught, resolved conflicts, and contributed as able to childcare, domestic work, and agriculture.  15 Children contributed actively and increasingly to familial work according to age and developmental level i.e. assisting with agriculture and household tasks such as collecting water, childcare, and caring for animals. These types of interdependent familial pursuits prevailed in the Acholi region for recorded history (Atkinson, 1994; Girling, 1960; Ominde, 1952).  1.3.2 The experience of war and displacement Uganda has been impacted by cycles of repeating violent conflict before and following colonial rule (Dolan, 2009).  This data in this thesis is related to the war fought in the north between 1986 and 2006. The Acholi were the primary Ugandan ethnic group involved in and impacted by the war. It began when the current government, the National Resistance Movement (NRM), first seized power in 1986 from the Acholi-dominated government and northern Acholi insurgent groups rose up in opposition (Refugee Law Project, 2004).  These insurgents had a number of incarnations in the early years but the last and most enduring was the rebel group called the Lord’s Resistance Army (LRA) led by Joseph Kony. The LRA, which was composed of both conscripts and volunteers, brought forth political, religious and spiritual agendas to motivate continued conflict and violence for more than 20 years (Dolan, 2009). The prolonged war was politically complex and vicious.  In referencing numerous authors who have written detailed accounts of the history, politics and nuances of the two- decade war in Uganda, this thesis focuses on those aspects most pertinent to care-giving and the environment of early childhood (Allen, 2006; Dolan 2009; Finnstrom, 2008; Gersony 1997; Refugee Law Project, 2004)  From the earliest days of the war, Acholi civilians were subjected to the destruction and looting of life-sustaining familial resources such as crops, cattle, and livestock. Community resources such as health and educational infrastructure were destroyed.  While initially government forces were the primary targets of most of the direct human violence committed by the LRA, in the early 1990s the rebels intensified their targeting of civilians. They resorted to mutilation to warn them not to speak out against the LRA, or to take side with the government (Dolan, 2009).  The violence decreased briefly between 1992 and 1994, but intensified again in 1995 with massacres and mass abductions initiated from LRA bases in Sudan supported by the Sudanese government (Gersony, 1997; Finnstrom, 2006; Refugee Law Project, 2004). Using unpredictable and brutal attacks on unprotected people going about their daily lives in villages, schools, camps, roads, and health centers, the LRA  16 terrorized the Acholi people and stole or destroyed community infrastructure. Violence against personhood was also rampant and included rapes, beatings, and murder. As the LRA had few human resources to fuel the lengthy conflict, it built and maintained an army through abducting Acholi people, many of whom were children and youth.  In 1996, the Ugandan government formally established ‘protected villages’ or internal displacement camps in urban or central rural gathering areas throughout the north.  In the years to follow, many people fled to such camps in search of safety. However, even more were forcibly displaced into them as the government gave many Acholi civilians only days to collect their lives and move themselves and their families to the camps before the military violently enforced relocation (Dolan, 2009).  As camp numbers grew, relief agency involvement in the Ugandan conflict escalated from five at its start to more than 60 by the end of 2000 (UNOCHA, 2001).  The government maintained military detachments in or near the camps that were charged with protecting the northern civilian population.  Unfortunately, that protection frequently did not materialize because its military forces were too few in number; were under-motivated and under-trained; and were too slow to respond, if they did respond at all.  LRA rebels waged continuing attacks on the camps that involved raiding, looting, destroying property, vicious personal attacks, and abductions. Reports suggest that camp occupants were not only victim to continuing LRA attacks, but to violence perpetrated by members of the military tasked to protect them, as well as fellow civilians (Dolan, 2009; FEMRITE, 2008; Finnstrom, 2006; Refugee Law Project, 2004; Spittal et al., 2008).  The insecurity experienced by people in camps drove many to multiple displacements as they moved from camp to camp and/or to towns in search of safety (Falk, Lenz, Okuma, 2004).  In 2002 the Ugandan and Sudanese governments established an agreement that allowed the Ugandan military to enter southern Sudan in order to attack LRA bases.  The operation, termed “Operation Iron Fist”, drove the LRA from their bases in Sudan and back into northern Uganda in full force, deeply intensifying civilians’ suffering (Dolan, 2009; Spittal et al, 2008).  In retaliation, the LRA expanded the war in 2003, moving into previously unaffected northern regions and substantively increasing the violence and abductions of civilians. It has been estimated that 66,000 Acholi between the ages of 14 and 30 were abducted during the war (Annan et al., 2008). With insecurity heightened even further, there  17 was again intensification of displacement. At night, thousands of unaccompanied children would flee their homes in search of safe places to sleep - becoming known as the “night commuters”.  Walking for kilometers to populated areas, they crowded into stadiums, hospitals, churches, under private verandahs and later on, into established shelters –any place they could find to sleep and hopefully evade abduction and survive (Falk et al., 2004).  Displacement continued to escalate and by the end of 2005 it was estimated that up to 2 million, or approximately 90% of the northern population, were living in camps (The Republic of Uganda Ministry of Health, WHO et. al., 2005). Reports on the camps stated that they were seriously overcrowded (with little more than foot paths running between shelters), unhygienic (lacking clean water and adequate latrines), and without essential infrastructures.   The displaced people in the camps were frequently hungry, abjectly poor, and forced into dependence upon international organizations and agencies distributing basic provisions (Dolan, 2009; FEMRITE, 2008; OXFAM International, 2008; Refugee Law Project, 2004; The Republic of Uganda Ministry of Health et al., 2005; UNHCR, 2007). The consequent high incidence of malnutrition, infectious diseases (including serious outbreaks of Ebola and meningitis), violence and mental health issues in the north were documented as being higher than national averages (Republic of Uganda, 2007).  Furthermore, the people living in camps largely lacked access to their lands and homes due to distance, curfews, total bans on movement, and the risk of landmines or being attacked by fighting forces should they attempt to go back home.   People were thus struggling or unable to assume traditional productive roles such as agriculture, livestock management, hunting and gathering (Dolan, 2009; Spittal et al. 2008; UNHCR, 2007). Between the raids on property and forced internal displacement, many of the northern Acholi became economically destitute and unable to successfully meet the needs of their families (Dolan, 2009, Gersony, 1997, Spittal et al., 2008). Under such circumstances social and cultural breakdown was rampant. Parents were understandably challenged in terms of their ability to nurture their children at the most basic level as well as their ability to teach their children the traditional values and practices that had sustained their people for generations (McElroy, Spittal, Atim, Tebere & Muyinda, 2010; Refugee Law Project, 2004; Spittal, et al. 2008). At home in their villages they were surrounded by kin, but displacement brought untenable living environments populated by strangers. For example, in 1998 the population of Pabo camp included people from 28 clans and 121 villages (Dolan, 2009).  18  While many reports and studies highlighted the disabling impact of war and displacement on the population (Accorsia et al, 2005; Bayer, Klassen & Adam, 2007; Bolton et al., 2007; De Jong, Komproe & Ommeren, 2003; Jamal 2003; Neuner et al., 2004; World Health Organization, 2006; UNDPCSD, 1996; UNHCR, 2004; UNHCR, 2007; Vinck, 2007), there are also reports of resilience (i.e. Blattman, Carlson & Mazurana, 2008) which deserve acknowledgement.  Reports of both kinds indicate the need for careful research into the effect of war on early childhood.  The violent conflict in northern Uganda finally ceased in 2006 with the signing and renewal of a cessation of hostilities agreement between the government and the LRA rebels (Dolan, 2009). The rebel leader Joseph Kony refused to sign the final peace agreement leaving a lingering uncertainty in the region. The Lord’s Resistance Army remains active today and continues to inflict terror in other African countries.  1.3.3 The aftermath of war and displacement When conflict ceased in the north, the Acholi people were skeptical about the success of the peace process. Previous efforts for peace had failed and fighting had always resumed after lulls, usually with an escalation of civilian casualties. There was no immediate mass movement back to homes in the northern Acholi districts because people feared that if they went on their own, they could be accused of rebel collaboration or pushed back by military forces.  So, they waited for a clear message from the government that returning home was allowed (Dolan, 2009). Some of the population moved to decongestion camps, that had finally been established in late 2006 after being called for numerous times.  Post-conflict transitions are often reported to be as difficult as living through active conflict (Machel, 2001; Wessells & Monteiro, 2008). The impacts of violence - such as profound loss, emotional and mental health impairments - persist.  At the same time returning home and/or rebuilding presents new stresses such as land disputes and unexploded ordnance (e.g. landmines) in return sites.  There can be a loss or diminishment of livelihood skills due to prolonged dependency in camp settings.  Return sites can also lack infrastructure such as health centers and schools, destroyed in war or fallen into disrepair.  Personnel for such facilities may have perished or relocated.  Governance can be strained and rates of poverty and unemployment can be high (Machel, 2001; Wessells & Edgerton, 2008).  19 As previously mentioned, by the end of the twenty-year Northern Uganda conflict, up to 90% of the population had been displaced into “protected villages” or camps. Many had lived in these camps for prolonged periods of time, most for more than a decade.  Transitioning back to rural agricultural subsistence living after such a prolonged period of displacement was neither simple nor straightforward (Oxfam, 2008). Rather, the process of repatriation and reconstruction, which was still ongoing in 2009-10 when this research was conducted, was complex, arduous and protracted.  A conceptualization of population mobility advocated by a study of HIV/AIDS in mobile populations is relevant to the post-conflict movement of Northern Uganda’s population.  This conceptualization views population mobility as a dynamic process with diverse manifestations that impact a populations’ vulnerability (Bronfman, Leyva, Negroni & Rueda, 2002). When the war in Uganda ended, life circumstances had changed for many.  Some found themselves with nowhere to return to or physically unable to return to their community on their own.  The majority who decided to return to their villages found that resources and infrastructure had been lost or destroyed. Rebuilding required considerable time and a great effort, but it had to be done before adult caregivers could relocate their children. Consequently, during transition, many Northern Ugandans were moving back and forth between the camps, with basic services and infrastructure, and the fallow regions that had to be rebuilt in order to become livable (AVSI, 2010; Oxfam, 2008).  1.4 Conceptual model The Total Environment Assessment Model for Early Childhood Development (TEAM-ECD) created by the World Health Organization Commission on Social Determinants of Health Knowledge Network on Early Child Development (ECDKN, 2007b) provided conceptual guidance for the line of inquiry explored in this thesis.  The model is based on evidence (peer reviewed scientific outputs, reports, and experts) from international sources, including low-income countries.  It explains the critical importance of the environmental conditions children are exposed to in the early years: The environments that are responsible for fostering nurturant conditions for children range from the intimate realm of the family to the broader socioeconomic context shaped by governments, international agencies, and civil society.  These environments and their characteristics are the determinants of ECD: in turn, ECD is a determinant of health, well-being and learning skills across the balance of the life course (ECDKN, 2007b, p. 3). The TEAM-ECD model posits that early childhood development is influenced by interactions  20 between the child’s biology and the multiple environments that surround or embed the child (ECDKN, 2007b). It builds upon the excellent work of many other scholars in the fields of child development, social epidemiology, public health and social determinants of health (ECDKN, 2007).  It is based on an ecological framework, originally formulated by Bronfenbrenner (1979), however TEAM-ECD expands upon Bronfenbrenner’s work, refining the scope of the environments that influence children and showing the interdependence and interaction between environments (ECDKN, 2007b). As the TEAM-ECD schematic shows, the model outlines the environments that are essential to providing the nurturance needed for healthy early child development.  These are referred to as ‘spheres of influence’ surrounding and embedding the child.  Figure 1: TEAM-ECD schematic  Irwin LG, Siddiqi A, Hertzman C. Early child development: A powerful equalizer final report. Vancouver, BC: Human Early Learning Partnership, written for the WHO Commission on Social Determinants of Health; 2007, p. 17. Available from: Permission to use has been provided by the Human Early Learning Partnership (March 8, 2012).  21 This model guided this research in northern Uganda by focusing the general direction of inquiry, i.e., the spheres of influence to be explored.  The child is surrounded by family (i.e., nuclear, extended) and the family is embedded in residential communities (i.e. neighbours in a village and/or displacement camps), relational communities (clan, religion, working groups - groups based on social bonds) and service environments (locally available ECD programs, health care, food supplementation programs).  These immediate environments are the daily context where the children grow and develop, but they too interact with and are influenced by an even broader socioeconomic context that affect large numbers of children:  The regional environment (i.e., health and economic status of the northern region, non- governmental organizations and local governments practices and policies, i.e., food distributions), the national environment (i.e., national government spending in the north, national policies and actions such as mass internal displacement strategy), and global spheres (i.e., international community who influence agendas, policy, priorities for spending).  The framework also incorporates a temporal component, acknowledging how actions in any and all of these environments can influence children’s holistic development (social emotional, language/cognitive and physical) in both present and future.  In the literature, TEAM-ECD has not yet been applied to conceptualizing how the environments of war and displacement act on children, however, conceptual models that recognize environmental factors are gaining recognition for the knowledge and understanding they advance regarding the holistic needs of children affected by conflict (Boothby, Strang & Wessells, 2006; Wessells & Monteiro, 2008).  1.5 Research question and study objectives  1.5.1 Research question How do the environments created by war and displacement act on early childhood health and development?  1.5.2 General objective To explore early childhood (0-3 years) in a population impacted by conflict and displacement in northern Uganda including knowledge, attitudes, beliefs, practices of caregivers and observable behaviours of young children.    22 1.5.3 Specific objectives 1. To explore Acholi caregivers’ and leaders’ perceptions of young children’s health and development in terms of: 1) holistic needs (physical, social emotional, cognitive- language) and protective factors; 2) threats, barriers or risks to child development, and; 3) short- and long-term outcomes when needs were not met or there was exposure to risks. 2. To understand both the current and traditional pre-war beliefs, knowledge and common practices in the care of young children from the perspective of caregivers and leaders emphasizing daily care routines, nutritional practices and techniques for promoting child health and development. 3. To record observations regarding environments and behaviour of young children living in displacement camps and return sites. 4. To comprehend retrospections and perceptions on the impact that war and displacement had on young children and caregivers from rural agrarian families. 5. To examine the post-conflict, post-displacement transition, focusing on young children and caregivers and the factors that promote and/or hinder early childhood health and development. 6. To formulate recommendations for policy and practice guidelines that focus on protecting hard to reach, vulnerable, young children during war and recovery.   23 Chapter 2:  Methods 2.1 Synopsis This interdisciplinary study of early childhood documents the experiences and environments of young Acholi children and caregivers affected by war and displacement in Northern Uganda. Over a one-year period, guided by applied ethnography, data were collected from a purposive sample of 162 participants using multiple methods including: focus group discussions (FGDs), interviews, case study, participant observation, photo documentation and document review. By taking a narrative approach, this study was able to draw on historical perspectives, present experiences and future aspirations.  This chapter describes guiding methodologies and conceptualizations, sampling methods, demographics of research participants, description of the research team, outline of the data gathering process and methods, translation process, analysis and knowledge translation.  2.2 Guiding methodology and conceptualizations There is a dearth of research on early childhoods lived in the potentially high-risk environment of war and displacement. As noted by Colson (2007), an anthropologist and scholar of forced migration, complexity is a defining feature of such situations.  Further, as illustrated by the conceptual model, TEAM-ECD (section 1.4), the factors influencing early childhood development are complex and multifaceted. Thus, in seeking understanding of a complex phenomenon - early childhood in war - a qualitative and interdisciplinary approach was deemed essential.   The interdisciplinary perspective included experts and literature from anthropology, population and public health, preventative medicine, occupational therapy and paediatrics. The exploratory qualitative tradition chosen was applied ethnography.  Ethnography, as described by LeCompte and Schensul (1999), “generates or builds theories of cultures – or explanations of how people think, believe, and behave – that are situated in local time and space” (p. 8). Done well, ethnography reveals the issues that are most vital and relevant to study participants and facilitates the expression of dominant perceptions (Boyden & de Berry, 2004). In the case of applied ethnography, a common and more focused form of contemporary ethnography, there is a narrowing in on particular issues that have been identified by the researcher and key local persons.  Thus applied ethnography departs from traditional ethnography, which encompassed a detailed study of all aspects of a culture.  Further, the results of an applied ethnography are meant to be useful/applicable  24 in addressing the issues of focus (LeCompte & Schensul, 1999). Ethnography is characterized by its conduct in natural settings; by intimate, direct and often prolonged interaction between researchers and study participants; by the use of multiple data collection strategies; and an inductive, recursive and interactive process of data analysis. Ethnography seeks to present “an accurate reflection of participants perspectives and behaviours” (LeCompte & Schensul, 1999, p.9) within their context and culture.  As recommended by ethnographers, and researchers working in forced migration studies, we left flexibility in the data collection plan in order to remain responsive to the transitioning population (Bloch, 2007; Colson, 2007; LeCompte & Schensul, 1999). The dialogue between participants and the primary researcher enhanced understanding and shaped the unfolding of the research process and the direction for subsequent data collection (Dona, 2007). For instance, the sites were not pre-determined, interview questions were used as guides with ample room for probing of emergent themes, participants’ suggestions regarding important characteristics for future participants were followed, and the number of interviews/FGD to be conducted was not pre-set but left open to saturation of important themes.  2.3 Sampling 2.3.1 Population and site selection The research was conducted in the Amuru district of Northern Uganda.  Amuru was a relatively newly created district (2005) under common governance and according to our key informants was under-resourced and under-served compared to neighbouring districts.  It was also reported to be a region greatly impacted by war.  There had been heavy rebel presence owing to its strategic location as a corridor between Sudan and Murchison Falls National Park - locales where rebels would base and hide. In 2005 the district held the greatest number of displacement camps in the Acholi region. There were 34 camps housing a population of approximately 257,000 (UNHCR, 2010).  The data collection for this thesis began in the Amuru district of Northern Uganda in June 2009, three years after hostilities had ceased and two years after the population had been granted freedom of movement.  When the study commenced a reported 37% of Ugandans were still living in the Amuru camps (UNHCR, 2009).  By the end of June 2010, most of the camps had been officially closed and UNHCR reported that only 14% of the internally  25 displaced population remained in camps and settlements (UNHCR, 2010).  The study occurred during the period when 23% of the Amuru population was in transition from displacement camps to village homesteads.  The target population was children birth to three years old, from rural agrarian families (the pre-war livelihood and lifestyle of the majority of the population in the region) who experienced conditions of conflict and displacement.  As this age group was highly dependent and unable to speak on their own behalf, the team used a mix of direct observation of children in their natural contexts and proxy respondents- family caregivers and community members directly connected to young children.  The study population came from villages and internal displacement camps within three sub counties geographically spaced throughout the Amuru District: Pabo, Amuru and Anaka. The villages and camps were selected purposively from the source population with the guidance of key informants to reflect a range of remoteness/accessibility, resource availability, and stage of resettlement/ repatriation of the population. Pabo Sub County Pabo camp had been one of the largest and most overcrowded camps during the war.  In 2005, one year before the end of hostilities, Pabo was home to 48,455 persons (UNWFP 2009) and when it was closed officially as a camp on February 24, 2010, officials reported that 9,159 persons remained. It had been a trading centre before the war and on the day it was closed Pabo was officially re-designated as a town board.  As such, it was an urban space with services and homes (round huts made of brick and grass thatched roofs) fanned out on either side of the main road, relatively easy to access with minimal driving and walking needed by researchers to access participants. By the end of the war, Pabo possessed community infrastructure as an outcome of the extensive emergency relief provided.  It had two health centers, a market with cement stalls, numerous shops, grinding mills, drug dispensaries, schools from nursery to secondary level, numerous international organizations, non-governmental aid organizations and community based organization offices and government sub-county offices. Due to barriers discussed later, not all residents had access to the range of services.  Pabo site was selected as a good source of information about camp life and about the early processes people went through when contemplating a return to their villages. The majority of participants from this site were still  26 living in the camp or in very early stages of transition back to villages. Omee II camp and surrounding villages in Amuru Sub County Omee II was a very remote and significantly smaller decongestion/transition camp and the research involved people in both the camp and its surrounding villages. The government of Uganda established transition camps later in the war to move people closer to their land for subsistence and to decongest larger camps. In 2005 Omee II camp was home to approximately 7,850 people.   Relevant to this research, it is notable that one-third of this population, or approximately 2500 children, were under the age of 5 (WHO, 2005).  Most of the people who lived in Omee had moved there from either Pabo or Amuru camps.  The site was selected based on the insight of grassroots leaders and government officials in Pabo who had returned to their villages and/or were doing outreach to remote communities. They described the challenges being faced by those who had returned to particularly remote and under-resourced areas.  Omee II was a rural site, difficult to access and very under- resourced. The sole primary school had been built by the community using local materials, and was in a state of disrepair with holes in the grass-thatched roof and walls crumbling in places. The community was supporting young teachers through small financial contributions or labour.  The market was small and had few items for sale consisting largely of local women who sat on the ground with their wares (usually vegetables) laid out in front of them. All but one of the water points in the camp was broken.  The nearest health centre (level 2), Ober Abic, was approximately 11 km away and it was only open during weekday daytime hours.  If an emergency occurred outside of these times, the nearest help was at Amuru health centre, approximately 25 km or an hour away on motorcycle taxi.  Omee II was difficult to access as the road was badly rutted with potholes filled with mud and water. As an example of the access issues and physical environment, the following is shared: After the first drive to the village in a car, the team was afraid the vehicle would not make it through on subsequent trips. We opted to park in Amuru and hire motorcycle taxis which could navigate around the deep holes. While it perhaps looked a little strange, we choose to wear trousers under our dresses to provide modesty as we sat on the bikes, to protect our legs from the sharp bush and grass that spilled onto the overgrown roadside, and to make it easier to navigate the difficult terrain.  Even with this measure, there were a number of occasions during the rainy season where the bikes skidded out in the mud and we had to stop and collect ourselves before continuing. On one occasion, when heading home we offered one of the motorcycles to a mother who had to transport a very sick child to the  27 hospital, while we (the two primary field researchers) rode together with the driver on the other bike.   The bike carrying the mother with an infant tied to her back and the sick child in front of her ended up overturned in a deep hole of mud and water. Thankfully nobody was hurt as the mother deftly managed to hold the children out of the water until we could come and pick them up. However, experiences such as these deepened our understanding of the tribulations people went through in trying to reach medical care when living remotely. Furthermore, we were told to ensure we left the field each day before it got dark as people had been waylaid and robbed on the road at night. When people later told us of simply praying to God if a child fell ill at night because there were no options for safe transport, we could understand how and why this was so.  Over the course of data collection in this camp, the population markedly decreased and structures in the camps were destroyed as people left. Most of the participants from this area were in early resettlement, rebuilding their homes and planting crops.  Some were still moving back and forth living between camp and village while others had recently returned fully to their homesteads. To capture the range of experiences, the research engaged participants who were experiencing both situations. The team traveled by foot from Omee II camp to the village homesteads, often hiking for an hour or more (figure 1).  Figure 1: Pictures depicting fieldwork team  The process of foot travel also revealed much about the challenges of returning to remote locations.  The routes to the villages were generally narrow footpaths, although we observed that skilled cyclists could manage.   Several of the homesteads visited were across flowing water.  In some places where water was particularly high, local bridges had been roughly constructed of piled wood to assist with crossing (see Figure 1), but for other shallow areas,  28 people simply waded through. Locals spoke of how rising water levels during periods of rain prevented travel and could strand a person on either side of the river.   On more than one occasion, the team observed people collecting muddy water to use for drinking, cooking, etc. as they waded through on their way to a research site. The villages of Anaka Sub County The third site, villages and a few camps in Anaka sub-county, was chosen based on observations made in the previous two sites.  The team noted a progression as families settled for longer periods - they rebuilt infrastructure and had increased security through their gradual and laboured reacquiring of resources such as food and shelter.  Therefore, for the third and final site, the team aimed to capture the various phases of post-conflict resettlement.  When data collection began in this sub county, the camps were nearly vacant so while the experiences of a few camp dwellers were gathered, most participants were settled back at home for periods between 1 month and two years.  Because the research team covered 8 parishes within Anaka and visited a variety of villages, there was also a range of infrastructure.  Villages closer to the main centers tended to have access to health care, education and water points (although those closest to where the camps had been were also reporting decreased land fertility due to overuse).  Those living farther away from the centers were more like Omee II with limited resources and difficult access.  The data collection in Anaka allowed the research team to reach saturation or data redundancy on many of the themes that emerged during the first two sites. That is, no new information emerged from subsequent data collection (Morse, 1995), and Anaka was therefore the final site.  2.3.2 Participant selection The sampling was purposive or criterion-based.  Participants were chosen due to their possession of the characteristics that allowed for in-depth exploration of the topic of study (Ritchie et al, 2003). There were two key inclusion criteria for focus group and interview participants: 1) experience of conflict and displacement and 2) knowledge or experience of young children as direct caregivers, community leaders working for children and/or people with decision-making power and/or influence in regards to the well-being of young children in the northern Ugandan context. Leaders were identified as the team became familiar with  29 communities and through reputation referrals (Brennan, 2006).  This method of recruitment involved asking community members who in their community worked for young children and then tracing the individuals mentioned.  Within these broad criteria, a heterogeneous sample (also known as maximum variation sampling) was sought to capture the breadth of experiences and maximize the potential for identification of all factors associated with the topic of study (Ritchie et al., 2003).  A total of 162 people were either interviewed or participated in one of 26 focus group discussions (FGD): 35 primary female caregivers, 25 fathers, 22 elders, 29 sibling caregivers and 51 leaders, both formal (teachers, health workers, government officials, NGO workers, village health teams, child protection committee members) and traditional (traditional chiefs called Rwot Kweri (male) and Rwot Okoro (female), traditional birth attendants). Table 1 provides an overview showing the diversity of interview and focus group respondents.  From among these participants, six families were followed as in-depth case studies. Each family had at least one child from birth to three years of age. All but one were selected from the first data collection site to allow for a long period of follow up.  Five lived in the camp at the time of selection so they could be followed through their transition back to the village (or not). One had very recently moved to the village.  Apart from this, we sought out children and caregivers with a variety of characteristics in order to get a diverse perspective.  For instance, children were both male and female; spanned the age range of interest from 0 to 3 years; had an assortment of caregiver configurations. While two of the cases were chosen because the children were noted to be experiencing challenges (i.e. malnourished; physical impairment) at the start of the study, even the cases who did not fit this criteria experienced illness after illness including severe malaria, respiratory infections, systemic yeast infections, anaemia, malnutrition, diarrhoea. See table 2 for further description.  Numerous leaders from the grassroots village level to the District government participated in this research (described in Table 3). Other leaders were engaged informally in dialogues during research introductions, or other activities where participant observation was conducted such as when the team was referring children to services. For example, district health officials, non-governmental employees and international organization employees, community based organization employees, physicians and nurses at the local referral hospital or health centers.  Data from these interactions were recorded in field notes and  30 demographic characteristics were not collected, so these individuals are not included in the tables below.  Table 1: Demographics of caregiver respondents # of  p ar tic ip an ts  P ar tic ip an t ca te go ry  M et ho d S ex  A ge  E du ca tio n (n ) S ou rc e of  in co m e M ar ita l s ta tu s (n ) # of  c hi ld re n (< 16  y ea rs ) Li vi ng  lo ca tio n 35 Primary female care givers (mothers, grand- mothers, aunts, step mothers) 31 Interview  1 FGD with 4 people F 16y- 72y None, 17  Primary level, 17  Religion studies, 1 Farming own gardens or casual labour for others. Married or living together, 23  Separated, 6  Widowed 6 1 – 8 children (Including biological and orphans taken in) Camp, 14  Transition, 3  Village, 16 25 Fathers 5 FGD with 3 to 6 people M 22y– 64y Primary, 23  Senior, 1  Diploma, 1 All farmers All married or living together (1 to 4 wives) 3-14 children (including biological and orphans) Camp, 10  Transition, 5  Village, 10 22 Elders 4 FGD with 4 to 7 people 14 F  8 M 42y-92y None, 15  Primary, 5  Senior, 2 Farming, small business owner, support from children, receives aid for extremely vulnerable. Married, 10  Widowed, 11  Separated, 1 4-11 children (including biological and orphans) Camp, 7  Village, 15 29 Sibling caregivers 6 FGD with 4 to 6 people 23 F  6 M 4y- 15y None, 5 (some young- have not started)  Primary, 24 (some not in school due to care giving responsib ility, distance to school or lack of school fees) N/A N/A 1-2 under their care. Camp, 14  Village, 15  (Most were born in camps or came during early infancy/ 1 child never lived in camp)  Further, in all sites people with disabilities were included, either a caregiver or the young child who was the focus of observation. Impairments experienced included: quadriplegia, amputation (from landmine), visual impairment, impaired mobility (unilateral high muscle tone from cerebral malaria), hearing impairment (from chronic untreated ear infections).  31 Table 2: Description of case studies 1) Healthy, well nourished baby girl, 3 months old at the start of the study.  Lived with her single (separated), teen mother and the mother’s siblings in a camp.  Mother had primary 6 level education and was in school before she became pregnant.  The maternal grandmother was around but their relationship was tumultuous. The camp was also their homeland, so they remained in the camp as the transition occurred around them.  2) Twins, one boy, one girl, 1 year 2 months old at the start of the study.  Lived with their mother and three older siblings in a camp.  The mother had been widowed during the war just prior to the birth of the twins.  They made an attempt to return to the paternal (deceased husband’s) village but failed due to a land dispute.  They were subsequently given a house in the camp by a brother in law and continued to live there at last report.  3) Boy of 1 year at the start of study (see Chapter 6 for full description). Lived with his family of 9 including mother, father, and 7 children.  They initially lived in a camp, but eventually resettled in family land just outside of the camp.  4) Girl of 1 year 4 months at the start of study.  Lived with her single mother  (widowed by her first husband and abandoned by her second husband), and 10 siblings (eldest children were away from home). They initially lived in a camp, but eventually resettled in the village after being referred to the Norwegian Refugee Council for assistance with repatriation.   5) Girl with a physical disability, 2 years, 8 months at start of study.  Lived in the camp with an aunt who cared for the child and 2 older biological children (she had 4 total but the older were married and lived in their own homes).  The aunt was a widow following the abduction and death of her husband by rebel forces during the war.  This family was unable to resettle in the village as they had nowhere to return (paternal kin rejected the woman) and were still living in a camp uncertain about the future (see Appendix A for full description).  6) Girl baby, 2 months old at start of study. Lived with her mother, father and 6 siblings (some were away for school) in the village.  The mother was inherited by her husband’s brother (child’s father) after her first husband was killed in the war. They shared a homestead with two co-wives and the children.   32 Table 3: Demographics of leaders # of  p eo pl e P ar tic ip an t ca te go ry  M et ho d S ex  A ge  E du ca tio n (n ) S ou rc e of  In co m e 12 Traditional Birth Attendant i.e., women based at the community level who assist with childbirth. 3 FGD with 2 to 7 people (dependent on the number of TBAs living in the particular village or camp). F 36y to 68y. The majority had been trained informally by their mothers or female family members. Only a few had formal training through Lacor Hospital Farming, casual labour, and/or savings and loan. 9 Government leaders: 1 District official 8 Local Council Leaders (Levels I & II) i.e. government officials working at the village level 1 interview  2 FGD with 3 to 5 people 8 M  1 F   24y to 54y None to university level Government job for district official.  Farming for LCs. 10 Health field: 1 Health worker from Health Centre level 3  9 Village health team members (i.e. community members trained to recognize health danger signs in children, distribute basic medication, make referrals, mobilize, etc.) 1 interview  2 FGD with 3 to 6 people 3 F  7 M  20y to 47y Primary level, 7  Senior level, 2  Diploma, 1 Government job for health care worker  Farming for VHT 7 7 Child Protection Committee Members (i.e. community members trained in children’s rights. Provide community education, report cases of rights violations, etc) 1 interview  1 FGD with 6 people 3 M  4 F Age unknown (approximately 20s to 40s) Trained through non- governmental organizations. Farmers 12 Rwot Kweri (Male) and Rwot Okoro (Female) (Traditional chiefs who share power and influence at the village level with the LCs) 2 FGD with 6 people 10 M  2 F 25y to 58y All primary level (P3 to P7) Farmers 1 Nursery teacher 1 interview F 22 y Certificate in nursery education Nursery teacher  2.4 Ethics Ethical approval was obtained through Makerere University (Uganda), The Uganda National Council of Science and Technology and the University of British Columbia (Canada). Informed consent was received from all participants.   When children were living alone in camps because their parents had re-located to the villages, we elicited the assistance of Local Council Leaders to track parents or the guardians in order to obtain consent.  Consent forms were read aloud to respondents in the local language to ensure that literacy and language were not barriers to providing consent. Assent was obtained from children who participated in sibling caregiver focus group discussions.  Confidentiality was maintained by removing identifiers from responses in reports and publications and ensuring the location for interview or FGD was out of earshot from others in the area.  33  2.4.1 Permissions, introductions and recruitment of participants Before initiating fieldwork, the team approached the district offices of the Amuru District to make introductions and obtain approval to proceed.  Meetings were held with the Regional District Commissioner, the Chief Administrative Officer and a number of people from the community development branch. We discussed the research and provided copies of letters of permission from the Uganda National Council of Science and Technology and the President’s Office.   It is important to note that this procedure is not only respectful, but is a required procedure.  Subsequently each time we began a new research site, we introduced ourselves to the Sub County officials for that site, and once again showed letters of permission and sought approval and guidance. Finally, before initiating data collection in the camps and villages, the local community level leadership was consulted, specifically, the Local Council Members in the region and/or the Rwot Kweri (traditional leaders). The officials were most welcoming of the research viewing it as a topic of importance for their communities.  We obtained permission from all of these levels of leadership to move freely in the area.  The community level officials assisted us in identifying participants within their communities according to the identified criteria.  This was the primary means of recruitment. Additionally, on occasion participants referred other participants, and on a few occasions, particularly in the camps, caregivers who had young children were approached directly by the team. This mixed method of recruitment helped to guard against situations where leadership may nominate and thus privilege certain groups for participation while silencing others (MacKenzie et al., 2007). If participants were not home at the time the team arrived, the team moved on to another participant and returned later.  The team was careful to avoid convenience sampling.  Several participants who were living in remote locations expressed appreciation that the team had reached them in their distant locales, for instance a 57 year old widow caring for 7 children in her return village in Anaka Sub County commented “I feel that it is good the way you have come here, you actually looked for us in the midst of the community.”  Comments such as these by leaders and family participants affirmed the importance of reaching remote populations in order to understand their unique context and challenges.  34 Compensation:  In acknowledgement of time spent on the research and therefore away from their gardens and household activities, each participant was provided with a token of thanks at the end of the interview or FGD, i.e. a bar of soap, a small bag of iodinated salt and a thousand shillings (approximately 45 cents US).  These items were decided upon with the Ugandan fieldwork and supervisory team who deemed them to be useful, beneficial to health of children and families, but not excessive.  2.5 The research team: background, training and team processes In addition to the interdisciplinary advisory committee identified earlier, the core fieldwork team consisted of a highly skilled and experienced Acholi researcher, offering the emic perspective (cultural insider) and a Canadian doctoral candidate (the primary researcher) with a background in paediatric occupational therapy, international health and qualitative research offering the etic perspective (cultural outsider). Two Acholi research assistants (RAs), one man and one woman, assisted with data collection on occasion in addition to working on transcriptions/translations and team discussions of emergent themes.  All of the Acholi team members had university level education and were fluent in both English and Luo. The experience and knowledge of the local team was essential to collecting credible data as they knew the nuances of local communication and culture.  For example, when respondents were asked to “describe your source of income” most responded “none”, equating this question with paid wages.  The local researchers then probed by asking “so how do you buy your soap and salt?” knowing that these are items that are regularly procured with cash.  This simple probe consistently elicited the productive occupations of the community participants, who were most often farming and selling some of the harvest.  The diversity of the advisory and fieldwork teams combined provided both investigator and theoretical triangulation. Triangulation is a concept applied in qualitative research whereby the topic of interest is approached from a number of different angles, such as a number of researchers from varied theoretical backgrounds, applying a range of methods (method triangulation) in a variety of sites (site triangulation). The purpose of employing triangulation is to offset weaknesses (e.g., flaws of one method are strengths another), challenge biases (e.g., from different researcher perspectives), improve the confirmability of findings (e.g., similar findings are emerging from different methods) and most importantly, deepen understanding of concepts by exploring different ways of knowing, from different angles (e.g., FGD get at the group norms whereas interviews highlight individual experiences and  35 differences) (Green & Thorogood, 2009). As noted by Mathison (1988), more often than not, triangulation does not result in convergence of data but elicits variation, complexity and a more complete picture of the phenomena under study.  Training and preparation of the core fieldwork team occurred over a one-month period and included background information on the content area of the study (the science of early childhood), review of data collection techniques (probing, clarifying, group facilitation) and team planning for assuring and maintaining strict confidentiality.  This last topic included no discussions outside of the research team unless following up on an issue authorized by the participant, giving transcripts numeric codes and removing identifiers, password protecting computers, locking up consent forms and clearing recorders and cameras of all data after each day of data collection.  Duties while in the field were divided. The Acholi Researcher conducted most interviews and group discussions in the local language of Luo. While the interview was in session, the Canadian researcher observed young children in their natural environments and did photo documentation of children engaged in their daily activities.  Permission to take photos was included in the informed consent process and was used for in-depth analysis of children’s activities and play objects. To avoid disrupting children in their activities, the researcher would generally sit just inside the open door of a hut, or outside but not directly in the children’s space so that she did not become the focus of attention and alter their behaviours. Observations were confirmed through discussions with the Acholi researcher.  Debriefing meetings between the researchers occurred every day on the journey home from the research site where observations, emerging themes, emerging data, clarifications, meanings and areas for further exploration were discussed.  The credibility of questions was also discussed, i.e., were questions and probes effectively eliciting information? Field notes on impressions, observations, challenges, and reflections were taken by both researchers and were kept together in field diaries.  2.6 Fieldwork timeline This research involved prolonged engagement in the field; an approach that helped to guard against misunderstandings that could have arisen from a short fieldwork period.  For instance, at the start of the study the region was in drought and children were seriously  36 compromised nutritionally. However, prolonged engagement revealed a change in context and improvement in children’s nutritional status, thus providing a more balanced perspective.  In addition, the prolonged engagement was positive for attaining a more nuanced, detailed, and deepened understanding.  Figure 2: Data collection timeline   2.7 Data collection approach and methods This study utilized interviews, focus group discussions, case studies, participant observation, photo documenting and document review.  Multiple data collection methods were chosen to strengthen the depth, authenticity, and credibility of the study through triangulation of data sources (Harris et al., 1997). For instance, by using a range of qualitative methods with a range of respondents, the likelihood of capturing the pertinent issues faced by young children was increased and so too the credibility or trustworthiness of the research. Furthermore, different methods revealed different facets of the topic under exploration. The larger, cross-sectional sample increased the chance that the variation or breadth was captured, but adding case studies followed longitudinally and engaging in prolonged participant observation also provided the very valuable aspects of depth and change across time.  To address the research questions and develop an understanding of how war and displacement acted on young children, it was deemed necessary to take a continuum approach, in other words, examining experiences and context across time. This approach involved attempting to understand cultural and traditional beliefs and practices utilized in villages before war; then to reveal retrospections and perceptions on the impact of war and displacement, and finally to look at the post-conflict experience. With post-conflict study, a  37 continuum approach was also deemed necessary as early data showed the transition process to have roughly three phases:  pre-transition, early transition and late transition (Table 4).  Table 4: Phases of post conflict transition Pre-transition Early transition Late transition Still living in displacement camps.  May experience barriers to return causing stagnation in pre-transition. Moving back and forth between camp and village while re-building.  May experience land dispute or lack of services causing stagnation in early transition. Relocated and living full-time in the rural village homesteads.  Accordingly the content of all data collection tools included both retrospective questioning, and questioning about current post-conflict transition experiences/context and knowledge, beliefs, attitudes and practices.  While it is acknowledged that retrospective methods can be limited owing to memory (forgetting) and distortions (exaggeration, revisions, reconstructions, falsehoods), triangulation helped to increase the trustworthiness of the data.  For example, retrospective accounts were compared with data from document review of historical records, and data provided by different categories of participants. The comparing and contrasting of change across time allowed for a more thorough exploration of the impact of war and post-conflict recovery.  Interviews and FGD were conducted in a range of locations such as homes (inside or outdoors under a tree), community buildings such as churches, or places of work (for leaders). Participants decided on the location and whether they wanted to complete the interview/FGD in one session or multiple sessions. Ensuring that the place chosen for the discussion was removed from others in the area provided privacy in all settings.  2.7.1 Semi structured interviews with primary female caregivers Interviews conducted with individuals lasted approximately one hour. The open-ended semi- structured interviews guides were formulated to explore the context of children’s lives and elicit perceptions about risk, protective factors and outcomes of young children’s health and development. The guides designed to bring forth knowledge, attitudes, beliefs, practices and perceptions about life circumstances/ environments of young children (sample questions in table 5) evolved over the duration of the study to fully explore new ideas as they emerged. Following interviews with primary female caregivers, weight and height data was collected  38 for the youngest child under 3 years as an objective source of data to corroborate caregiver’s perceptions about nutritional status.  2.7.2 Focus group discussions (FGDs) Focus group discussions averaging 4-6 participants lasted approximately 2 hours (ranged from 35 minutes with sibling caregivers to 5 hours over 2 sessions with elder women). Open-ended semi-structured interviews guides were used (see table 5 for examples of questions).  The groups were often single gender in an attempt to achieve homogeneity. This approach to group formation was chosen to increase feelings of safety and maximize the shared experience (Pope & Mays, 1996). Focus group discussion allowed people to discuss topics together and build on each other’s memories and knowledge; this was particularly helpful for retrospective portions of the research (Bernard et al, 1984). FGDs with fathers, grandparents and sibling caregivers captured the perception of family members that make up the major part of a young child’s social network, other than their mother/primary adult female caregiver. The inclusion of sibling caregivers was deemed critical as these children provided much of the daily care and stimulation in Acholi culture.  In addition, children’s voices in research that is relevant to their lives is gaining recognition as a critical contribution to comprehensive understanding of issues in complex situations (Boyden & Mann, 2005; Triplehorn & Chen, 2006). Elders (both male and female) offered the greatest depth of perspective on the past including traditional childcare strategies.  They described with authority how things had changed during war. Fathers are an essential part of young children’s’ well-being, yet they are often marginalized in terms of their roles in families and not included in research and interventions relating to young children (ECDKN, 2007a). This is likely due to the fact that they are traditionally not the primary caregivers of children and often do not perform the day to day care roles such as feeding and bathing. Nonetheless, the inclusion of fathers offered valuable insights into the lives of young children, the dynamics of families, and they spoke eloquently to the environments of war and post-conflict.        39 Table 5: Sample guiding questions Post-war living arrangements: • If still in the camp, explain why? • Tell me about the impact of remaining in the camp for your children: • If in the village, tell me about your return to the village: • Tell me about the impact of returning to the village for your children:  Current service environment: • Describe the services that are currently available for young children: • If present, how effective are they? • Who are the existing or potential leaders who are (or could) address the needs of young children in your community?  Nutrition: • Describe what you should feed [NAME]: • Is there anything that makes it difficult or stops you from feeding [NAME] these foods? (probe: environment factors, social factors, # of times issue is experienced) • Is there anything that helps you feed [NAME] these foods? • Describe what happens when you cannot feed her/him the foods you describe:  Health: • Describe what [NAME] needs to be healthy: • Describe a safe and happy environment for a young child: • In the last two weeks has [NAME] been ill? (Probe illness and treatment)  Caretaking practices: • Who spends the most time with young children? (Probe who takes care when caregiver is away or busy). • How are young children supervised?  Developmental stimulation: • Describe what children learn in the (1st, 2nd, 3rd year of life- ask according to age): • How do they learn each of the skills you mentioned? • What does play look like for a child this age?  (Probes: whom do they play with? Show me what he/she plays with.)  Young children in war and displacement: • Describe what was different about raising young children before war when people lived in their villages: • Did this change during war? (Describe)  Risks/barriers and enhancers/facilitators: • What is bad for young children? (i.e. what could prevent them from being as successful as possible?) • What should be done to make sure [NAME] and all young children have the chance to become successful adults?  Future outcomes: • What do you want for [NAME]’s future?  (Probes: valued outcomes, measures of success, desirable character traits).     40 2.7.3 Case studies As Colson (2007) states, following people over time “inevitably leads to a better appreciation of the transiency and vulnerabilities, of the influences that impinge to transform people’s lives…” (p. 325). These families were followed over the course of this research with one visit occurring approximately every 6 weeks. The cases were selected to represent a range of familial situations, although we could not anticipate initially how their transition would unfold. On the first visit, the semi-structured interview guide (used for all caregiver interviews) was used with the primary female caregiver. At the end of these interviews, we asked the six families for consent to continue on as case studies. The primary female caregiver continued to be our main informant however other family members including fathers, grandparents and other kin contributed to discussions as they became familiar with us over time. On all subsequent visits the topic of discussion was left open-ended to allow for the most salient issues to emerge. Often these discussions would begin with questions like ‘how have you and your child been?’ ‘What has occurred in your lives since we last met?’ Some of the families were asked to participate in a photo activity and took photos of situations that they felt were ‘good for their children’s development’ and ‘bad for their children’s development’ (Personal Communication, Aisha Yousafzai, May 2009).  These were then used as a basis of discussion as they explained why they had chosen to take each of the photos.  These case studies allowed for in depth exploration of young children’s lives and environments over time during post-conflict transition. Case study families discussed the challenges of resettlement with the research team as they were experienced and the children were followed as they grew, developed new skills and sadly as they went through a cycle of poor health and poor nutrition. These narratives, or telling of stories, brought depth and nuance to the data.  The extended engagement also allowed for the building of trust as everyone came to know each other and hence, more detail was forthcoming.  Participants would frequently tell spontaneous stories of their own and their children’s experiences since the last meeting, as illustrated by the following excerpt from the field notes of the Acholi researcher: We exchange greetings and she begins straight away telling me that ‘you would have been invited for the burial of ______’ (the three year old child she was caring for) and I ask what happened and she begins narration and I decide to just record because she was speaking so fast….    41 2.7.4 Participant observation and photo documentation Living and working in the research sites afforded numerous opportunities for recording observations of informal interactions that shed light on the context of young children’s lives, a technique called participant observation.  Some of the types of observations made have already been illustrated in the description of traveling to and from the Omee II research site. Many informal discussions occurred throughout the days, such as on long walks with participants and or community leaders who were assisting with recruitment, in car rides, or over lunch.  Additionally, the fieldwork team on a number of occasions referred children who were part of the study to services such as hospitals, or to NGOs such as the Norwegian Refugee Council, for assistance with repatriation.  These daily social interactions provided further insight into the topic of study (Eastmond, 2007) and the two primary field researchers recorded prominent features of these experiences in field journals.   As Green and Thorogood (2009) explain: “Observational methods allow the researcher to record the mundane and unremarkable (to participants) features of everyday life that interviewees might not feel were worth commenting on and the context within which they occur” (p.148). For example, adult participants rarely elaborated in their descriptions of children’s toys because most children didn’t really own ‘toys’ in the conventional sense of the word and tended to play with discarded objects found in the environment.  But observation showed a wide range of toys built from trash and objects being used creatively, which revealed much about children’s creativity, adaptation and play activities.  In addition to the many observations described, substantive amounts of time were spent observing young children, with parental permission, and recording what they were doing, how they were doing it, with whom and where in their daily lives and natural settings.    The observations were primarily recorded by the Canadian researcher in field journals and were confirmed with the Acholi researcher. Observations included care practices such as feeding, hygiene, sleeping; children’s preferred activities, for example play (also captured through photographic recording); social interactions between parent-child, sibling-child, child and peers; and notable aspects about the child’s observable environment such as play spaces. Children were far from stationary unless ill and would frequently move outside of the observable range, resurfacing later. This was particularly challenging in the camps where the huts were packed so closely together that a child could disappear quickly.  Interestingly, caregivers also lamented this problem experienced by the researcher, providing an example of how method triangulation allows for confirmation of data. It was not practical for the  42 researcher to follow the children when they moved out of sight as this would draw attention to the researcher rather than the activity the child was intent upon.  Nonetheless, due to the prolonged period of fieldwork, observations were captured over time, and periods of movement around the camps or between homesteads also afforded many opportunities to observe children in their daily endeavours. These observations of young children in their natural environments proved important for capturing behaviours that were missed or not covered in interviews and behaviours that differed from reports or beliefs (Pope & Mays, 1996).  For instance, many caregivers spoke of how camps had “spoiled” children (i.e. children were disobedient, did not follow cultural norms, etc), but few spoke to children’s adaptation.  Observation allowed the primary researcher to fill in this important gap, and this data became the basis for chapter 6.  Another example was when the team noticed many young children in camps seemingly unattended by adults or even sibling caregivers.  This prompted further probing about the supervision of children.  2.7.5 Regional and community leader interviews or FGDs Leaders were engaged either in interview or FGD depending on the category of leader. There were fewer upper management positions, such as district officials, who oversaw children’s affairs, so these people were generally interviewed.  As we moved to the grassroots community leaders, there were greater numbers of representatives.  Therefore, in order to capture the range of experiences and allow participants to build on each other’s answers, FGD was used.  By talking with leaders we were able to identify the most salient issues to the community in regards to the well-being of young children and explore the broader community environments in which children lived. For example, leaders were very knowledgeable about situations in the community that made children vulnerable such as food insecurity, neglect or abuse.  They spoke knowledgeably about resources and infrastructure such as services and policies that were currently in place to address children’s issues, were proposed for future implementation, and/or were lacking or dysfunctional.  Additionally, it was the goal of the team to not only use the research process as a means of data collection but to promote dialogue and reflection about children’s development and actions that could promote development in the local environment.  Therefore at the suggestion of reviewers from the Child Health and Development Centre at Makerere University (Uganda), at the beginning of the leader interviews we included a reciprocal dialogue about early childhood development (ECD). This collaborative component allowed  43 us to ensure that during the FGD or interview with leaders we had a common understanding of ECD.  For instance, instead of simply asking “What is early childhood development?” listening to the answer and moving on to the next question, the researchers also shared their understanding of ECD and discussion ensued.  We repeated this process for other questions like, “Why is ECD important?”, “What are the risk factors for ECD?”  This process proved invaluable for promoting an atmosphere of sharing of information and several participants spontaneously commented at the end that they had learned from this dialogue. It was further evidence of Reed (2006)’s assertions that the research process promotes reflection that can in itself promote novel ways of contemplation and action. Really you have not wasted our time, what we have obtained from you is so big because if it is possible that what you have shared with us at the beginning could be followed well, we would have a big difference in the lives of our children.  Focusing on the future of our children is what is very important; we must look deep into what we should do for our children.  What ways can we help our children? – 30-year-old Rwot Kweri, from village surrounding Omee II.  2.7.6 Document review Document review involved reading government and non-governmental reports, meeting minutes and news stories for information relevant to child-focused services provided or lacking. Topics of interest included health, education, nutrition, agriculture, and anything directly relating to young children such as breast feeding, nursery school. Relevant clippings and minutes/reports from regional meetings were pasted into field books or stored on the computer, providing an additional rich source of data and offering the institutional perspective on situations (Green & Thorogood, 2009).  2.8 Translation process The question guides for each category of respondent underwent a rigorous translation process to ensure concepts and meanings remained consistent from English to Luo. The steps for translation outlined by Wild et al. (2005) were used as a guide: 1) forward translation by two independent translators, 2) reconciliation, 3) blinded back translation of reconciled version by a third translator, 4) Canadian researcher reviewed back translation for discrepancies between translation and original meanings, 5) as a group, discussed discrepancies and agreed to a final version.  Notably, there were few discrepancies, thereby increasing the confidence in the bi-lingual language skills of the team, 6) each tool was piloted to ensure that it was culturally relevant and comprehensive.   44 Interview and FGD recordings were transcribed in Luo and then translated into English by one of the team members.  The team sat together during this process and as language ambiguities arose they were discussed and a Luo-English dictionary was consulted in order to come up with translations that most accurately reflected the meaning; for example, the English terms growth and development are both expressed by one Luo term, as are poverty and suffering.   Random portions of translations were verified by a second person.  2.9 Analysis 2.9.1 On- going analysis during data collection Qualitative data analysis was an iterative, on-going process from the beginning of data collection. A team approach was utilized during analysis to ensure thoroughness through alternative interpretations (Barbour, 2001). During data collection, the core field research team met weekly to discuss emerging themes and the effectiveness of questions. Probes were added, modified or eliminated in order to tease out the phenomena under study and ensure relevant and meaningful data was collected that would fulfill the objectives of the study and bring clarity to the exploration. For example, questions about child development were eliciting answers primarily focused around physical development.  Because this was an interesting finding it itself, the broad question was retained and respondents were probed about cognitive, language and social emotional development.  LeCompte and Schensul (1999) offer a clear description of the reasoning behind on-going analysis in ethnography: ….ethnography is usually conducted under conditions of some uncertainty about the direction of the study, the kinds of data that will be most relevant, and even which questions are most salient to ask. Researchers may have begun with a research question or the desire to explore the origins of a specific social problem, only to find out when they are in the field that the original problem is not a problem to the research participants in the field or that a different issue is much more important…Or, the researcher may have begun with a general theoretical model or way of thinking about the world only to find that this model is not congruent with the way people in the field explain their world (p. 6-7). The analytical process engaged in by the core team was supplemented by sharing passages and preliminary ideas with other co-investigators from the doctoral committee for feedback (both Ugandan and Canadian), and presenting ‘research in progress’ to a panel of professors from Makerere University prior to the final data collection phase.  Engaging feedback and analytical input from both near and far throughout the data collection process added rigor to the analysis and helped frame key themes/categories.  During on-going field analysis we attended not only to information that was confirmatory of  45 original formulations, i.e. ideas that occurred repeatedly or substantively, but to the negative evidence that appeared to disconfirm what we had already discovered (Miles & Huberman, 1984 in LeCompte & Schensul, 1999). This involved looking for items that were unusual, rare or absent. Attention was given to contrasting information such as outliers of response (unusual responses) in order to build in protection from selection bias during analysis and bring into perspective the variation in the population (LeCompte & Schensul, 1999).  For instance, while most of what we heard about displacement to camp living was negative, one respondent told us of the benefits (i.e. protection offered), which expanded our understanding and led to further questioning of this perspective with other participants.  2.9.2 Analysis following data collection The next phase of analysis was to reduce and organize the large amount of raw data which amounted to over 1700 single-spaced typed pages of transcripts, two large hand written field diaries, and numerous reports (governmental and non-governmental) saved to the computer hard drive and pasted into field diaries. The ‘data corpus’, or all of the data collected for this research (Braun & Clarke, 2006), was large and broad and it was deemed necessary to focus the analysis for the purpose of this thesis.  Thus, after several readings of the data corpus to get an overall sense of the content, the data set used in the analysis (and presented in this thesis) was based on ‘analytic interest’ (Braun & Clarke, 2006) in early childhood before, during and after war.  In other words, the analysis focused primarily on data that had reference to how war had altered children’s pre-war life, the actual experience of war and the recovery from war (specific objectives 3-5).   To extract this data set, all of the transcripts were imported into HyperRESEARCH qualitative analysis software. Field notes were analyzed manually as these were handwritten. The transcripts were coded initially at a very high level of inference, i.e., codes were assigned to large extracts of data that referred to pre-war, active war, post-war transition. The software program was then directed to generate a report of raw, grouped data for each objective. This provided summarized datasets to which more detailed coding and analysis could be applied.  Once there was a manageable dataset generated, thematic analysis was applied.  This involved noting when “certain phrases, events, activities, behaviours, ideas or other phenomena occur repeatedly in the data” (LeCompte & Schensul, 1999, p. 46), and devising a code (or label) for these data segments according to their message, or what they were about. Once again, the software generated reports of raw data excerpts delineated by these  46 codes.  The ideas under each semantic theme were then summarized and grouped. For instance “socioeconomic environment” was the label used to encompassed statements about poverty, household resources, crop failures, food aid, etc. The analysis compared and contrasted between and within participants’ reports, categories and typologies were generated and dialogue ensued about meaning of the data with team members (Green & Thorogood, 2009). Attention was given to both information that repeated regularly, and information that was unusual or presented alternate perspectives.  Furthermore, patterns and relationships in the data were also sought.  For instance, the data on “socioeconomic environment” was examined across participants in different phases of post conflict transition, from those still living in camps to those who had been settled in villages for varying lengths of time.  Doing this allowed for exploration of associations between resettlement, resources and reports of children’s status.  This process was completed in consultation with the advisory committee and reviewed by the fieldwork team to ensure agreement on results of the analysis.  2.9.3 Interpretation Finally, an interpretation of the results was formulated (i.e., the meaning of the data): the discussion in the final chapter of this thesis.  Interpretation involves taking the results that show regularities, relationships, and experiences and highlighting the important findings, linking them with literature, partners’ perspectives, and providing the bigger picture that shows how this knowledge is important for future program and policy innovation (LeCompte & Schensul, 1999).  2.10 Feedback and knowledge translation As Mackenzie, McDowell and Pittaway (2007) point out, there is a great risk of research being exploitative to vulnerable communities and concerted effort must be made to ensure that research gives back to, or benefits in some way the participants who share their time, knowledge, experiences and trust. This was an underlying goal of this research and during the research, the team engaged in advocacy and referrals on behalf of communities and even individual families in cases where resources were required (and permission given to do so). As a result of such advocacy work, some participants gained access to services such as health care, nutritional supplementation and assistance with repatriation through Lacor hospital, the Pabo Health Centre and the Norwegian Refugee Council respectively. Additionally arising from a partnership of the primary researcher, international organizations,  47 community based organizations, community members and government officials, 6 community based early childhood programs were planned and implemented in return sites in 3 districts of the north, including Amuru.  Furthermore, following data collection, the Acholi researcher returned to communities to dialogue about the results of the study, respond to wishes expressed for additional information about early childhood, and answer questions. As is noted by Wessells and Monteiro (2008) who worked with young children in post-conflict Angola, recovery in post- conflict requires re-acquiring control and efficacy at both the personal and collective levels. A critical aspect of child development is that nurturance occurs at the family and community level. Hence, participants who become aware of and engaged in stimulating their children can have immediate and long-lasting impact. The reciprocal sharing of knowledge through dialogue was intended to promote control and action at the community level, if deemed necessary by communities (Jason, 2004).   There was some difficulty locating participants who had re-located to their home regions following data collection; in such cases local leaders and community representatives who would have contact with a range of community members were included in the dialogue and information sessions so they could feedback to their communities. Additionally, attempts were made to return to district officials during on- going data collection to report back emergent findings however, we found officials difficult to locate/ access, and/or some had been transferred.  We therefore focused feedback on key informants such as the District Community Development Officer in charge of ECD. Furthermore, as reports are completed, these will be distributed to relevant parties at the district and community levels.  48 Chapter 3:  The impact of war and displacement on traditional physical protection strategies employed with young children  3.1 Synopsis In northern Uganda war and mass internal displacement arose from ubiquitous power and resource inequities; from historical, political, economic forces that created a situation of intense and prolonged conflict.  These macro level phenomena had a profound impact on the conditions that children were born into and grew up in.  In turn, these conditions affect children’s health and developmental trajectories. This qualitative research study documented participants’ accounts of the impact of war and displacement on traditional childcare and protection strategies in a rural agrarian population. This chapter contrasts and compares retrospective narratives of pre-war, with accounts of active war and internal displacement.  Through this approach, it is possible to gain understanding of the profound transformation that occurred in the lives of young children and their caregivers.  As the volume of data collected for this research is substantial, the results pertaining to the conflict and displacement period will be covered over the first two findings chapters.  This first chapter has been delineated into three thematic areas that capture participants’ perspectives on strategies used to physically protect or meet the biological needs of very young children: 1) structuring the daily living environment; 2) food and nurturance in early childhood; and 3) health knowledge, beliefs and practices.  Each thematic area will be presented in three parts: 1) an introduction to the theme; 2) participants’ accounts of traditional pre-war rural agrarian conditions and experiences; and 3) participants’ experiences of war and displacement. This order of presentation facilitates temporal comparisons and sheds light on the mechanisms by which war and displacement heighten very young children’s vulnerability through compounding health and development risks.  3.2 Findings 3.2.1 Structuring the daily living environment for young children Acholi participants recognized infancy as a tenuous time in the human lifespan when children were highly dependent and somewhat fragile.   Children during this period were described as not yet “conscious” of themselves and their surroundings; hence they required physical protection, attentive care and teaching about what was safe and what was  49 dangerous.   There were several Acholi proverbs that spoke to the fragility of young children, as shown in this exchange between elder men in a focus group discussion: Participant 1-  The proverbs related to children are like this, 'a child is an egg' and the meaning of this proverb is that a child is still young, therefore it is an egg and you are aware that eggs can break any time so at any time you can lose a child, that child. Facilitator- So what then must be done so that the egg does not break? Participant 4-  the egg must be kept very carefully. Participant 3-  because then it cannot yet protect itself.  Participants noted that a failure to adequately monitor and protect young children in a safe environment could have numerous repercussions, including death, injury or disability that impeded later functioning in life, damaged beauty, and or emotional scars leading the child to grow with bitterness.  3.2.2 The Acholi village:  Protection through place, space and peace In the rural village before war, the Acholi lived in round huts constructed of mud bricks (or mud and wattle) and grass thatched roofs, spread out within spacious compounds.  Families were patrilineal, thus the compounds housed the extended family of the senior male of the household.  The family member’s homes were generally arranged in a circular formation around the compound with communal space in the middle. Family members would monitor and control the space, keeping children away from risks like sharp objects and fire, particularly when they were very young and not yet aware of the physical dangers in their environment.  While under the supervision of adults and the care of a lapidi (child babysitter), young children were free to play in the family compound. … (With) a crawling child, when the child wants to go and touch fire you say 'awaa! awaa! (Danger)', then they will realize that should I touch this thing here it will cause problems for me, or it can be said 'koko' (bites!) referring to such things that crawl on the ground such as caterpillars, worms and what have you and the child will know that such things are dangerous and such even when the child sees such a thing, he will fear to play close to it and this will have saved him from many dangerous things. – 40-year-old married father of 4 living in a displacement camp in Anaka Sub County after 12 years in displacement Natural environmental dangers aside, the traditional homesteads in the village were felt to be safe places.  Most homesteads were not on busy roads so there was little risk of a child being hit by bicycles or motor vehicles. There were wide-open spaces, fresh air and shade to shelter children from the hot sun.   The homes were not locked so children (or their  50 babysitters) could go inside to get food and water as needed and/or to settle inside for a sleep with the breeze blowing on them through the door.  The distance between homesteads was reported to be far and separated by agricultural fields and bush, so young children were removed from external influences.  They generally remained within the bounds of the homestead and within ear and eyeshot of their caregivers.  Respondents stated that this relative isolation made it easier to protect children. Visitors to the family homestead were usually kin who provided care and support. While there were mixed reports about feuds and fights in the past, most respondents generally recounted a peaceful existence and a quiet atmosphere.  There were mechanisms in place for mediating and resolving conflicts and most children lived without fear. Children in those days because homes were far apart it was easy to take care of them.  They would not walk aimlessly and even when people would go to the garden because the huts in a home were all around in one compound. – 34-year-old married mother of 4.  3.2.3 War and displacement: The loss of protection, place, and the emergence of violence and chaos People spoke of how suffering multiplied when war intensified in the region. Quiet, peaceful villages were invaded by the sounds of fighting, often unpredictably, and rebel attacks were a constant threat.  When such attacks did occur, caregivers would run with young children in search of a place to hide and take shelter.  The following excerpt illustrates the experience of violence, chaos and fear through a primary female caregiver’s account. The rebels came to her village twice.  The first time they stole cattle and goats as well as abducted, then killed her husband and one child; the second time, they looted crops: I was right there hiding at their feet (rebel army), I was there, I stayed there and they kept moving until they all flowed (went) away.  I tried to get up but I was only struggling with my chest.  My whole body was finished.  I crawled on my chest and went and hid under the canopy, under the fig tree.  There I lay.  Then I heard the two children who had survived... He said:  'mother is no more, today mother is no more, they have killed her also, we are now finished. Mother! Have they killed you also today? Did they all flow (go away)?’ ‘Yes’, I told him, 'be quiet, I'm alive' Then he said 'mother, are you alive?' I answered ‘yes’. 'If you are alive, come out in the open'  51 Then I crawled and came out into the open.  I tried to organize food for them to eat. The children would try to eat, but in vain- they were too disturbed.  We ran and slept in the bushes; in the water, in the middle of the water (an islet).  The rocks surrounded it like this.  I placed the children on the rocks.  I folded blankets all around them and my eyes were opened watching everywhere as I squatted there.  I stayed awake until the day broke.  It was a full week that I spent there sister, in that stream.  Everybody had run away.  Then my daughter …came up during the daytime and they collected me from there.  I struggled to move with hesitant steps, but I could not move.  Here (the camp) she brought me sister.  The troubles of this war have overburdened me, I can hardly talk about it.  When people talk about the war, I just keep quiet in their midst.  I simply squat there when my spirit is gone out of me. When I stayed there in the middle of the stream with the children, I would hear the lion growling nearby. It eats the birds as I listen and I would plead with my mouth, 'if I have committed a crime, then you can come and eat me with my children, but if I have not committed any offence, I will spend the night until daybreaks on me'.  But, my daughter came and collected me sister. You just see me? I am just a shadow that you see.  The children that have remained (alive), I did not know I would have them, but at least I have struggled with them.  I still shake my head amongst them, yes, for the war has done me bad.  When I hear people talking, I remain dead silent, for me I cannot talk, I keep quiet, it keeps on making my heart jump over and over.  A human being is taken from your midst, and killed, two people in fact!  And you are still there alive; they have left you, just on purpose.  All your things are plundered, can you still be a human being? –57-year-old widow caring for 4 grandchildren. Living in a camp receiving food assistance for the extremely vulnerable The chaos of the fighting interrupted caregivers’ ability to provide children with consistent basic daily care such as feeding, bathing and providing shelter.  Sometimes people would execute plans to hide their children in the bush by creating rough shelters or finding other safe places under brush where the children would be protected from abduction and harm. Women reported sneaking away from these places in order to find food or to cook for the children, thus keeping the cooking fires from revealing their children’s’ locations.  As the war continued and attacks on unprotected civilians escalated, the participants were among the population that was moved (often forcibly) into displacement camps or “protected villages”.  However, attacks continued in the camps. ….during the time of exchange of fire, parents who had many children suffered a lot when it came to running away.  They would struggle to carry a child on the back, carry others on the arm, carry others on the chest and running became so difficult for them with their children. This made the parents face very difficult lives.  – 21-year-old mother of 1 living with her spouse in a village in Amuru This war made people come to the camps and children suffered very much in the camp, the camp would be attacked and children would run and sleep in the bush… Children suffered from the cold because of sleeping in the bush - there was nothing to cover them - many suffered from cold a lot.  We would run at night after hearing gunshots.  We would pick up our young children and run.  The very young ones suffered a lot because some of them were unable to run… Many young children died  52 in the water trying to cross streams and rivers.  They would run not knowing what direction they were going.  They did not know if the water was deep or not.  The children would run in one direction and the mother runs in a different direction. Very many young children were found dead in the water.  They found their bodies floating in the water.  They were running to save their lives but ended up dying in the water. – FGD with elder women in Pabo camp Aside from running and hiding, there was little caregivers could do to protect themselves or the young ones. In addition to the terror and chaos of fleeing, children were victim to direct violence.  Respondents told of infants bashed against trees or slashed with a machete while tied to the backs of their caregivers.    Children also witnessed brutal attacks on their parents and other family members including the horrors of rape, torture, killing and abduction. Caregivers recounted how the youngest children were sometimes the only ones spared abduction because they were too young to take. This war has made all of the children perish because Kony (rebels) can come here and collect the children and he just goes with your children, all of them.  If they come in great numbers, even if you have 8 children, they can take all of them, I may remain with one, the one who is on my lap or perhaps the other young one only because those ones can hardly go with them.  Moreover, you can’t prevent it. – 34- year-old widowed mother of 8, living in a village in Amuru Sub County When people moved into overcrowded camps in increasing numbers from the mid 1990’s onwards, extended family members were often scattered. Although the camps were large and sprawling, they were packed tight with huts. The air was not fresh and conditions were dirty, and children had little play space. One respondent recounted how “many children who were very young used to get lost within the camp and leaving parents so worried about their children.  The children would be found the next day or after very long hours.   This made life very difficult for parents...”  As the doors of the huts in the camp had to be locked to prevent theft, they were often not accessible to young children during the day when caregivers were away working. The grounds of the camps also posed physical hazards to young children such as pits that had been dug for new latrines, sharp objects on the ground, or used condoms that young children would suck on or blow up like balloons. Camps were often located near roads, making children vulnerable to road traffic accidents.  These disturbing reports were emphasized through participant observation when the research team helped to transport a child who had been hit and killed by a truck to the family’s place of burial in the village.    53 Fire struck the closely packed huts in camps at regular intervals, often because children would try to cook but were unable to control their cook fires.  The fires damaged and destroyed property, literally leaving families without a roof over their heads until tarps were delivered or caregivers collected grass in order to fix the roof, and repair and replace the burnt parts of huts that could be salvaged. Further, in two of the six case study families young children suffered from burns (two in one family, one in the other). One child had burns on both feet after another child pushed him into the fire, another had a burn on his knee from where a fellow child had poked him with a hot stick from the fire, and one suffered a burn on the arm from falling into the cooking fire while unattended.  Nonetheless, while the majority of the participants (both those who continued to live within camps and those who had resettled in villages) spoke of the camps as detrimental to children’s well being, several expressed the view that the camps had saved their families lives.  Their encounters with rebels in the village made them terrified that they would be killed or abducted if they remained in the village, so the camps were seen as preferable to home.  However, both historic reports about the camps and participants’ accounts reveal that abductions, rapes, looting and killing continued to occur within the camps.  3.2.4 Food and nurturance in early childhood Nutrition was the need for children most commonly identified by all categories of participants and insufficient nutrition was the most commonly identified risk. Breastfeeding of infants was the norm, with the introduction of solids in the form of cereals, usually millet or sorghum, at 4 to 6 months.  Then, children progressed gradually to an adult diet, the process reaching completion between the ages of 2 and 3.  Participant’s defined adequate nutrition in terms of the quantity, quality and variety of foods as well as children’s satiation, strength, weight gain, health and improved immunity. Furthermore, they noted that a nourished child would play, explore, feel happy and progress naturally through developmental milestones (e.g., physical skills like walking); develop intelligence; and perform well in school. Over the long term, adequate nutrition was linked to productivity, such as an individual gaining the strength needed to perform hard agricultural labour.    54 The moment they are not given food and they are not satisfied, they will not walk, they don't even crawl. What does food do to them? Food strengthens the feet. - 4-year-old girl who cares for her two-year-old sibling  3.2.5 Food security and protection against hunger in the village When we asked the participants to discuss how life was in the past for young children, the majority spoke of food and the practice of growing food as a primary means of protecting children. Families worked hard on their homestead lands to produce a range of foods (i.e. millet, potatoes, rice, sesame, ground nuts, beans, and green vegetables) that provided them with a balanced and varied diet.  In the Acholi tradition, foods were (and still are today) often “pasted” or coated with a sauce made of groundnuts or sesame that made them filling and nutritious for children. Crops were planted so that the yields coincided and yielded well in most seasons.  Reserves were stored in granaries on the homestead or at the sub county, so there was little need to buy foods.  Some participants called May to June “the hunger gap” due to a gap between yields, but serious hunger was rare: During hunger, the father and the mother when they notice that the foods are becoming less and less, especially during the dry season, they must ensure that they heap (plant) potatoes by the streams so that they are there.  And sometimes if it is raining, you make sure that you plant potatoes higher, on the drier areas, and those are days when the millet grains are not yet ready for harvest so the potatoes are there to protect children from hunger. – 38-year-old married mother of 8, Amuru People were also familiar with the foods that grew wild in the bush, including an abundance of fruits such as mangos, papaya, and wild plums, green vegetables, and root vegetables such as wild yams and cassava. They knew which foods had toxins and how to prepare those foods in order to ensure that the toxins were neutralized.  Many participants reported that the males of the family would hunt or trap game meat. Additionally, most households had cattle and/or other livestock such as goats and hens. Oxen could be hooked up to ploughs to allow for the opening of greater expanses of land. Cows were particularly valuable to young children because cow’s milk could nourish them when breast milk was unavailable or needed supplementation (i.e. orphaned children, weaning children, or children whose mothers were away working in the garden). …we had milk that used to help us, it was used for feeding the children, the young ones, cow milk was there for the young children, even those 1 year to 3 years and such categories of children would not feel any lack, even when the mother was not near or not around the child would not feel bad because the babysitter will have also  55 kept some of the things or the grandmother also would have kept some of the things or grandfather will have kept some of those things. – 58-year-old elder man, husband of 2, father of 8 living in village in Anaka Sub County  Cattle and livestock also offered a form of insurance as they could be sold in times of hunger to procure the foods needed for a balanced diet.  Alternatively, the money earned could further a family’s development by paying for a child’s school fees or cover the cost of transporting a sick child to hospital. In the past when people were still living in the villages, in relation to hunger, if there was some livestock available then sometimes you might slaughter and exchange it with grains like millet, sorghum.  You could take a certain number of kilograms in exchange, so that was one of the ways of helping people out of that problem; those days when people were still living in the villages. That is what our fathers were doing; it was like that in relation to food and livestock.  Sometimes you would go and exchange a line of cassava for a goat. That is what used to happen, when you don't have.  So you go and strike a deal, they count for you the lines of cassava and in exchange you give a goat.  Those were the good methods used. The methods I saw helping people in times of hunger in the villages. – 45-year-old husband of 3, father of 9 living in a village in Anaka Sub County As illustrated, in traditional Acholi society what people grew or owned in terms of living wealth (e.g., livestock) was their primary resource and the basis of child protection. Food that was produced was eaten, stored or given to kin, but generally not sold for money in any substantial quantity.  If people did work for others they were usually compensated with food or soap; if they did earn money, the amounts were usually small.  Hence, the collective extended family was generally self-sufficient and the children were well fed. … when we were growing up with my younger brothers and sisters our mother used to give us varieties of foods.  There was a lot of foods, like pigeon peas we would eat it in a split form, we would eat it pasted, we would eat green vegetables like bo, malakwang, which were all pasted.  Paste was all the time cel (string net for suspending a bowl under the ceiling of a house).  They would put the odii (paste) in the cel for us to eat before food is cooked, we would eat it with boiled cassava or roasted cassava.  There was always plenty of honey in the dry season and we would eat when food is not yet ready.  There was plenty of food.  She used to change diet for us, like game meat, there was plenty of meat because our father used to hunt. There was plenty of chicken being kept and we used to eat them.  Children used to have enough to eat and I did not see any child malnourished when I was growing up. – 34-year-old married mother of 4 If one household cooked, all children in the vicinity would be invited to eat. And since the different members of extended families all brought food to the wangoo (campfire) at night, the range of foods available to consume daily was broadened.  This was also considered to be a strategy for protecting children: ... as the adults sit by the evening fire, when food is ready from the various houses it  56 is brought to the elderly person by the fire.  That means that even for the child whose mother is not there (orphaned), he will be able to eat with the elderly person at the evening fire until he is also satisfied…even if a particular woman wanted to deny any of the children her food, at the evening fire that child will eat until he is satisfied and later when he is ready to go to bed, he will go to sleep when he is happy because he has a full stomach...- 58-year-old husband of 2, father of 8 Lastly, when caregivers went to work in the fields surrounding the compound, they left their children snacks such as cooked potatoes, cassava, pastes that could be scooped with a spoon, porridge made of millets or other grains, fruits, ground nuts, or sun dried greens sprinkled with salt.  This heightened participants’ confidence that the children in the village had sufficient nourishment to grow well and be healthy, strong and resilient to disease.  3.2.6 Food insecurity and hunger during war and displacement People talked about how the war deprived the Acholi of their ability to protect their children with food. They recounted mass looting of their properties, with most losing all of their cattle and livestock, and often, their stored foods. We had varieties of things, but now you see that there are so many things missing. In the first place the war came and in and there was this issue, they (fighting forces) would say 'let me borrow your goats, when we win the war, we shall pay you back'. Then another group on the other side, as well they would come and they would slaughter without even asking you and if you refuse they simply kill you, they don't want you to rebel.  Such things like our chickens, they would simply take.  Some of them would just come and uproot cassava and just go away with it.  So it has caused us Acholi to experience a lot of problems and this suffering if it could stop, let it stop forever, let it stop completely. - 34-year-old father of 6 Tragically, if their resources were not stolen, they had to be abandoned as people fled or were forced into camps. Many people were given little time to move to the camps and had no substantial means to transport their resources.  Most moved on foot, carrying their children and whatever else they could hold, but generally, household stores were left behind.  There was limited space to store foods or keep livestock in the camps and people who did have such resources had to lock them in their huts or else they would be stolen. Consequently, many people became partially or totally dependent on food aid, particularly in the last years of the war following Operation Iron Fist when violence, displacement, aid dependence and hunger increased dramatically (data from document review, Spittal et al, 2008).  Food aid was consistently described as being insufficient to meet the needs of their family. They said that food would frequently run out before the next distribution and then they had to wait as their children went hungry.  Rebel activity and looting of distributions further interfered with distributions.  57 … to live and survive I had to wait for each and everything from World Food Programme.  That has made it difficult for me, it has made my life difficult in the camp, it was not good….When I lived in the camp it was difficult to take care of young children, there was nothing you could use to take care of them, there was no food. – 20-year-old mother of 2 and caring for 2 others with her spouse Further, many reported that the camp diet was not balanced or nutritious. It was mainly composed of maize, beans and cooking oil, so children were not getting a sufficient variety of nutrients in addition to being hungry much of the time. A few participants reported that food quality was dubious in that it was bitter or rotten. Others noted that the foods they were allotted were not the staples of the Acholi, who valued millet and nut based pastes and felt cooking oil to be a very poor nutritional substitute. Their best efforts to feed the children often fell short of meeting their children’s needs.  Women breastfeeding children were themselves under-nourished.  A number of women said that their infants would suck on the breast for comfort, but were getting almost no milk (a behaviour we observed during the interview process).   In camps, they began to see signs of serious malnutrition as they watched their children’s health deteriorate.  They became familiar with services such as growth monitoring, and feeding units.   Some participants reported that children died as a result of malnutrition or being unable to fight off disease.  A document review conducted by the researcher found reports that corroborated participants’ perceptions about food insufficiency and its repercussions for children.  For instance, in 1999 the World Food Program reported: “in the camps corneal ulceration and childhood blindness caused by Vitamin A deficiency is widespread, as are deficiencies of Vitamin B and iron.  Both have contributed to growth retardation, mental as well as physical...” (WFP 1999 in Dolan 2009, p. 17). Terrible things happened in the lives of children during this war… children suffered so much from malnutrition.  It was really rampant in the camp because there was no balanced diet, there was no food to alternate, you could not go back home to dig and plant varieties of foods for the child to eat, consequently the children suffered a lot from malnutrition and because of that many children were put on feeding programs by the UN (United Nations).  Some even died from that problem of malnutrition, so life was bad for the children… - FGD with Local Council Leaders, Anaka Sub County  I heard you talking about death- that many people have died; they are dying as a result of what? Because of hunger-people become weak and when sickness like malaria comes in, the malaria that affects the brain, they are taken to the hospital and they are always found not to be having enough food nutrients. They are always referred to the Gulu Lacor (one of the main referral hospitals in the area) and mothers of these children, they again delay at home to prepare themselves before they go to Gulu, so the children end up dying.  So it is hunger and diseases killing  58 children. There are others who even reach the hospital but before anything is done to the child, the child dies.  The child dies before treatment. – Traditional Birth Attendant FGD, Pabo Camp  Many displaced caregivers continued to seek means of earning a living, usually relying on their skills in farming and crop cultivation. Those with lands near the camps often traveled there to cultivate crops or rented the lands out to others. However, yields lessened over time due to soil degradation from overuse and/or animals around the camps eating the crops. Some of those whose lands were too distant to access would rent small portions of nearby land or would work as agricultural labourers.  Alternatively or concurrently, some people operated small-scale businesses to deal with the food scarcities in the camps.  For instance, some traded goods such as alcohol or charcoal, while others collected water as a means to earn income. One respondent who had lived in Anaka camp reported that fetching one jerry can of water, including the time needed to wait in line at the water source, and the strain of carrying it on the head back to the customer, could earn 200 shillings (~ .08 cents USD). In such daily pursuits caregivers were away from their young children, but there were often no adult kin to provide care and supervision, as there would have been at home in the past.  People leaving the camps to generate food or earn income had to deal with security restrictions on movement as outlined by government forces.  Sometimes movement to and from the camps was restricted to certain daytime hours and sometimes there were total bans. Restrictions were often enforced with physical violence. Even when bans were not in effect, caregivers faced significant risks to their personal safety whey they moved back and forth to cultivate, hunt and gather.  These risks included landmines, bombs, and the chance of being attacked, raped or killed by the members of fighting forces. Yet, many persisted in leaving the camps to do their work, putting themselves at risk for the sake of their children. It was us the women who were courageous for the sake of our children saying that if it is for our children, then we would rather die….That is why the women had to keep on sneaking back, to carry food.  The men would not reach the villages at all.  The women were suffering for the sake of their offspring saying 'my child, my child, my child must not die of hunger', yes, but the men would not reach at all; they would not reach the village. – 59-year-old widow, caring for 7 grandchildren in a village in Anaka Participants reported that fighters on both sides of the conflict mistreated them when they left camps as their loyalty to each side was questioned. The consequent physical insults and injuries left many in chronic pain and physically weakened, thus impacting both their short- and long-term ability to work and to provide and care for their children. This is illustrated in  59 the following excerpt from a FGD with elder women in Anaka Sub County:  Participant 4-  Lakwena (rebels) beat us so much, we were several of us and they used machetes.  So, your chest pains you because you have been wounded in your body, this is because they wanted money.  After that if you are digging in the garden like this, it really pains so much. Participant 7- they beat you with a pestle as well (as in mortar and pestle- approximately 2 feet long and made of hard wood). Participant 4-  and they even beat people on their joints and that is where I also feel the pain up to today. Participant 3-  for some of us our arms was broken. Participant 1-  Because of Lakwena, we have wounds that are found on our backs. Even the other one was beaten with a machete. Participant 2-  All of us here, all of us, we have all been beaten. Participant 7-  Surely, we have become very weak…Then, this other issue of carrying heavy loads on your head while we had gone into the camps.  You come back to the village and you had to carry food, you must carry firewood as well when you go back into the camp. You carry it on your head, you carry as if you are dragging yourself and you go into the camp.  Then the next day you come back and carry food, then you carry firewood, all of these years doing this, it has weakened people, we are so tired also. Participant 6- then you must also carry the loads given by Lakwena (temporary abductions to carry loads for the rebels).  It has made everybody become weak.  Even parents were vulnerable, you carried things that you ought not to, that you could not carry, they threw it on your head and you had to move with it.  It caused us all injuries. Participant 5-  you carry their luggage up to the other side of Aswaa, those biscuits given to young children at the hospital (nutritional supplements for young children looted by rebels), I carried it and put it on my head in a basket, I went with some up to Aswaa, as they walk they keep on pushing you.  With traditional subsistence livelihoods thwarted, food aid insufficient and not even firewood for cooking in the camps, people were thrust into a cash-based system in order to supplement the meager rations of food, firewood, water and other goods that had previously been accessible in their villages.  However the poverty brought on by displacement, often meant that what could be procured was insufficient.  In many of the camps, there was a charge for a jerry can of water and in Pabo camp specifically, participants reported waiting for hours to fill up at the borehole due to high demands from over-crowding.  Less access to water meant limitations on cooking, drinking and bathing, which all impacted young children. In the past, people used to have their own homes with your own well and you wouldn't pay for water, you would not use money for buying so many things, but in the camp here when you still don't have money, you will not drink water.  When there is no money, you will not eat. When you don't have money, you may not have  60 firewood, so you may not cook.  These (conditions) have all been brought because of the war, this war has caused a lot of problems in people's lives, it has changed a lot in people’s lives; I find life very difficult, at times my children don't get enough food, my children may even become thieves because they don't get satisfied.  A child may see somebody else's food and may desire the food, then in the end may end up stealing it.  Even I as a mother may not spend most of my time with my child because I have to go and look for means of getting food… - 27-year-old mother of 7, living with spouse in Pabo Camp When moving back to their own agricultural lands wasn’t possible and the available food was insufficient, some caregivers begged from their neighbours or somebody who owned land near the camp, promising to pay them back when food aid came.  A FGD with elder women in Pabo emphasized how people learned to be more frugal, measuring their food before cooking and taking care not to waste anything.  The women reported that poverty made them wise in that they no longer gave excess food away to kin, as was their common cultural practice, but instead sold it for money. This new economic practice therefore meant that traditional Acholi means of supporting their children were altered.  Food scarcity and poverty also created social dysfunction, such as various instances of theft.  Some people had money stolen during break-ins to their camp homes; poultry owners had eggs stolen the moment they were laid, food was stolen from gardens outside of the camps; and scams played out whereby land was rented and cultivated, then confiscated back by the owners before the harvest.   Some participants admitted to uprooting food from others’ gardens outside the camps because there were no other means of survival.  There were also numerous reports of children becoming thieves out of desperation.  Sometimes this involved scavenging for discarded foods and other times the children stole either food or money from their own homes or the homes of others  All of these behaviours increased the insecurity and vulnerability of the families in the camps, as they could not trust that they could keep the few resources they possessed or that others, such as kin members, would provide what they needed.  Additionally, stealing violated a traditional and highly valued Acholi social norm. I harvested sorghum and put them in sacs to bring them home. I carried the first sack and brought it home and when I went back to get others I was chased away and threatened.  I ran away and when I went back with other people to check so that I could bring my sorghum home, I found it gone. ~25-year-old separated mother of 2    61 3.2.7 Health knowledge, beliefs and practices All categories of participants consistently reported that health was a primary need for the children, second only to food. Participants were not asked to specifically describe what ‘health’ meant to them, but their comments generally referred to the absence of diseases, good nutrition, a positive affect, and high levels of activity (i.e., playing).  Health was deemed a prerequisite for growth, appropriately paced development, happiness, intelligence, play, school performance, and success in the future. The child will look healthy, the child will play very well, a child wakes up early and will not mind about coldness - the child will run outside to play.  If a child does this, then you will know that that child is growing well.  If a child sits in the same place bending their back like a frog, then you know that that child is not growing up healthy.  If a child is healthy a child will always play, the child will always dance.  You will find the child playing everywhere and you will find the child always happy.  Such a child is a healthy child.  – FGD with Traditional Birth Attendants, Pabo Camp  3.2.8 Health in the village Participants reported regularly that in the past, children had been nourished, healthy, strong, and infrequently ill.  Even when children did become ill, they recovered readily and their conditions were unlikely to cause chronic health issues (excepting serious conditions such as measles). I can still remember when the war was not yet there because we Acholi, God gave us wisdom which always stays in our minds and we really know how to take care of children. …This is how we used to take care of our children:  we used to give them good food, we always treated them with good hearts, we protected the lives of our children and this is how we used to do it.  Early in the morning we would go to dig because of the children. We would plant varieties of foods and when it comes to herbs (traditional medicine), there were roots of plants we used to dig up and give to children who are healed and they would live.  Because we didn't have hospitals or health centers or we did not know about the hospitals or health centers. Very few people knew about hospitals and health centers and our children grew up with strength, without having many problems and many people would make comments that children in such and such a family are growing very well, they are getting enough food to eat.  They are being taken care of well. That is how we were always praised and our children grew up very healthy. - Elder women FGD, Pabo Camp Traditional Acholi health care was a well-developed practice, which intermixed beliefs about what caused illnesses with an elaborate knowledge of how to treat them.  As the above quote illustrates, biomedical health services had not been readily accessible to participants in the past, so they reported limited experience with them.  However, there were numerous traditional local practitioners who specialized in various health needs.  Participants reported that when a child was ill or developmentally delayed, they first consulted elders who had  62 vast experience in assessing and diagnosing health conditions. Elders would then offer advice about the actions people should take to address the child’s issue or recommend consultation with a health practitioner (a witchdoctor or herbalist), or biomedical doctor. … (a child who) cannot walk or cannot talk, or cannot do what is appropriate for his age.  First of all I see them go to consult the family elder, they would ask him … ‘what could be the problem?' and so the elders also will respond in a particular manner.  They will say that perhaps what is disturbing this child's proper growth and development could be such and such a thing.  Perhaps it is the spirits demanding for some traditional ritual of a particular type.  So, something has to be done in this manner and so the elders are given the opportunity to speak.  Then they will start searching out certain things, perhaps something quite small (something to pay the witchdoctor with), and maybe if they fail to get, then they will have to go to the hospital. – 25 year-old man Child Protection Committee Member, Amuru Sub County The Acholi traditionally believed that disease or impairment was frequently attributable to spiritual causation.  For example, when we asked participants what they would do if they had a child who was developmentally delayed or had congenital anomalies, some replied they would suspect that “Jok” (a particular spirit) was involved and seek out the help of witchdoctors.  For different spiritual causes there was a corresponding range of prescriptive rituals to be performed. Some of the practices included eating certain foods, taking herbal treatments, or making animal sacrifices.  Acholi health practitioners also treated various childhood ailments with a wide range of traditional treatments. For instance, children with respiratory conditions causing a very hard, fast pulse in the chest and fevers were sometimes brought to traditional healers for excision of the millet seed (meaning that a piece of fat was cut from the child’s chest).  When infants had fever, shivering or diarrhoea, their incisors (baby teeth that had not yet descended) were sometimes removed with a razor blade.  It was believed that the child would continue to get fevers or have breathing problems unless these procedures were performed. Further, throat inflammations that caused the child to cough and lose appetite were treated by first scraping the throat (tonsil and uvula region) with a razor, then applying herbs. Some practitioners specialized in draining abscesses.  Herbal remedies were frequently prescribed for common childhood ailments such as candida infection, colds, diarrhoea, malaria, stomachache, ulcers, and burns.  Various preventative and curative plants and roots were gathered and prepared in order to treat such ailments.  These were taken orally; blown across children’s noses; sprinkled in children’s mouths; smeared on affected areas; or added to a child’s bath.   63 Participants reported that such treatments had varying levels of success.  Some reported that herbs were their first line of treatment, but if the herbs did not work or the child’s condition worsened, they made the lengthy trip to a biomedical health centre: … it was our grandparents that showed us these herbs. I have been taking care of many of my grandchildren and I have been treating malaria using pwombo.  I mix it with the roots of lacer, I grind it, mix it with water, give it to the child to drink and the child gets better. I have about 3 to 4 types of herbs I use, there is one that is called Abuka, and it is even sold in town.  That herb, you dig it out of the ground and give to a baby who has gripping pain (colic).  You grind it very soft and then get sim sim oil and mix it with it, but the sim sim oil, you must ensure you boil it first before mixing it with that soft herb. …  If you fail with that, you may go and dig out the roots of alwak, the roots of alwak are for intestinal worms. You wash the root of the alwak very well, you grind it, mix it with water, you sieve it, then put it into the mouth of a baby, especially when the baby cries a lot. Such babies or children, always their stomachs make noise like 'currrrrr'.  After drinking, that noise may stop and the baby will not cry.  The baby will begin sending out soft poos.  Those are the herbs we used to use and even when I gave birth, that is what I used to use and that is what Acholi used to do.- FGD with elder women, Pabo Sub County  There were certain bad practices whereby rituals were conducted, especially when a child would convulse because of malaria, they would just slaughter a goat for the ritual, they would sing songs and they would try to chase the evil spirits but in the end the child still dies. Because there was no medicine administered the child.  That is why I say there was no benefit. - FGD with fathers, Pabo Sub County As the last quote illustrates, participants had mixed views on the effectiveness of traditional treatments. They acknowledged that these treatments could be harmful to the child because of a practitioner’s failure to properly diagnose the condition; because they could leave wounds on the child (such as failure to get permanent adult teeth); or because of complications such as sepsis, which could result in a loss of life.  Participants also acknowledged that some diseases such as syphilis, leprosy, measles, polio, and tetanus had no local cure. However, they felt that the substantial distance between homesteads functioned as a protective strategy in that it limited the spread of such diseases.  The institution of quarantine was a further protective measure.  For instance, if there was measles in a homestead, various signs were posted at its entrance to ward off entry by outsiders (such as placing a stick or pouring ash in the entrance of the home). Additionally, elders sent out a person out to warn the rest of the village when a person had an infectious disease and the affected person would be isolated the home until he or she recovered or died.   64 3.2.9 Health in displacement camps during war Parents felt like they could not protect their children from contagious disease in the camp environments, especially since huts were so closely packed together. Diseases spread readily in the overcrowded, unhygienic and dirty camp conditions.  Coverage of latrines and bathing shelters was insufficient in some camps; soap was not always an affordable commodity; and as described previously, water could be difficult to access.  Young children who were not yet continent would defecate around the huts, in the places they would play. Caregivers reported that they mitigated the risk of this behaviour by disposing of children’s faeces in latrines, but it was difficult to maintain hygiene under such conditions.  Many diseases spread through the camps quickly causing loss of life, such as diarrhoea, meningitis, and cholera. Participants also reported an increase of conditions such as severe malaria (that brought on convulsions), systemic yeast infections, and skin rashes in the camps.  In general, they observed that children were much sicker and weaker than they had been in the past and that the sicknesses were far more serious. The scarcity of food exacerbated the incidence of illnesses among children and caused conditions like the “food disease” (i.e. kwashiorkor). Consequently, children required more hospitalization.  Some participants spoke of great numbers of children permanently impaired and how child mortality rose. Many of the caregivers reported that they had lost one or more children to disease during the years of war. What this war has done in the lives of young children whose age are three and below is that when we were living in the camps, there were various sicknesses, there were so many diseases in the camp.  So we lost so many children's lives for that matter. Those children beginning from 0 to 3 years.  That was the result of being put in one place because if there was some distance between people's home and the homes were separated like this, in my opinion, such things would not have happened.  So it really cost the lives of so many young children.  Children who should have had a good future.  We lost them, at least quite a good number of them in the camp. - 37- year-old woman, member of the village health team, Anaka Once again, report content during document review was congruent with caregivers’ reports. A health and mortality survey conducted in the camps in 2005 suggested that the mortality (U5MR) rates of children under five years old were well above emergency thresholds (i.e., 2.31 per 10,000 per day).  Between January and July of 2005 there was an estimated excess mortality of 10,054 deaths among children under five (or 1000 excess per week). The leading causes of child death were malaria/fever and a disease constellation that included diarrhoea, thrush and malnutrition (The Republic of Uganda Ministry of Health, WHO et. al., 2005). Even when these diseases did not kill or permanently impair children,  65 the children endured a state of malaise and listlessness that inhibited their natural tendency to communicate, engage and play.  Several participants talked about diseases such as HIV, which were not present in the past but had been introduced as result of the war and displacement.  Some attributed the spread of HIV to soldiers and their relations with, or rape of, women.  They remembered how some women were raped when they went to their gardens to work for food for their children. Further, they spoke of changes to social norms in the camps, such as increased promiscuity, infidelity, and survival sex (i.e., sex in exchange for food or money), which increased the spread of sexually transmitted infections. Many participants were greatly dismayed feeling that HIV was everywhere, spreading among families and even afflicting infants before they were born.  It also left a wake of orphans who could not be adequately cared for by impoverished family members. One respondent described HIV as the silent war in the camps. … it is HIV/AIDS of course. You should not hide the issue, it is not a secret.  We were mixing carelessly, so the war brought for us the mobile soldiers who came and spread so many diseases and that is why these days there are so many weak people that have been left behind and these people who have been affected are just as bad as they have left orphans behind so you as the man who has remained behind or the woman who has remained the widow you have the task of feeding them, up to 10 plus when your ability can not cope with this.  This has caused us poverty in this area and has brought us suffering and this suffering is still worsening. – 46-year-old separated father of 10, village Although there were exceptions, respondents (both family and leaders) generally had a high level of knowledge about common diseases, including their causes, prevention and the need for treatment. However, researcher observations made during data collection indicated that this knowledge did not always translate into practice.  Very dirty children were seen regularly in camps, people shared drinking cups, and health care was not always accessed for sick children. Caregivers reported that barriers in the broader environment, including poverty, inadequate time, and a focus on survival, prevented them from doing what they knew was required. We must share one cup (for drinking) since we don’t have the ability to buy and provide different cups – it’s not there. What is the advantage or disadvantage of using one cup to drink water? It spreads diseases of course because now if one person is infected with the flu, that one cup will spread it to the rest. - FGD with primary female caregivers   66 Many of the traditional health treatment practices persisted when people moved to camps even though there was greater access to biomedical care (in the bigger camps). These practices reflected understandings about causation and beliefs about the effectiveness of traditional treatments.  Sometimes the continued use of traditional practices was related to costs and accessibility issues. However, participants generally reported that the use of traditional practices declined in the camps. Some said that this was because of the widespread health and medical education available in camps. Some concluded that herbal treatments simply weren’t effective on the stronger diseases that struck children in the camp environment. Personally I think that the result of applying Acholi herbs mainly were bad.  Only that God merely helped people because you do it haphazardly and then you believe, you think it will work….you know that it is just by luck that some of these things would work and they would get healed because for anything that you believe in, it will help you. ….In the past, it used to be the food that would protect the body from certain sicknesses… But today now that we have the problems with food, if you try the Acholi herbs you find they don't work.  It doesn't mean that that Acholi medicine changed because of the foreigner’s medicine but only because the nutritious food that used to be there has disappeared in the child’s body because there is no food. That is why most times children’s lives are lost and that is the reason why these herbs have lost their value, and that is how people have been seeing it. – 25-year- old husband of 2, father of 3, living in a camp Many participants reported that biomedical care and hospitals had considerable benefits, and became highly valued during camp living. People turned out in great numbers to health education sessions in camps, which addressed a range of topics (HIV/AIDS, malaria, nutrition/supplemental feeding, mosquito nets, child spacing methods, and hygiene and sanitation techniques such as not sharing drinking cups and disinfecting water). This education also actively discouraged participants from performing traditional practices considered by health care workers to be detrimental to children. Some participants reported that health workers would reprimand caregivers if children were brought in with wounds that suggested traditional procedures had been used. Several of the respondents, particularly those in leadership categories, began to think of traditional practices as dangerous to children as they came to accept health care workers’ directives and medication or treatment prescriptions health care centers. … [war] made us come to the camp but it also helped in such a way that it made us get what we were not getting when we were still in the village.  When we were still in the village there were people who did not value health services, but when they came to the camp, they started valuing the health centers.  Like for example malaria, when we were still in the village people would say someone is 'demon possessed' when a person shivers from fever.  Convulsions they were calling the disease of the winnower 'odero', but now, when a child begins convulsing you run with the child to  67 the health centre ... – 42-year-old married mother of 5 living in village in Amuru Sub County  Conditions such as measles and polio that used to disable or kill people were reported to decrease in the camps.  Access to immunization concurrently increased and people become more aware of the value of immunization. Accessing antenatal care also increased as people were educated about and experienced the benefits of such services.  Although the health care provided in the camps was beneficial to many children, as previously indicated, there were barriers to receiving this care.  For instance, people in remote camps found it difficult to travel to access health service locations and health centers often lacked medications and food supplements for malnourished children.  Finally, poverty prevented the purchase of prescribed medicines and/or transport costs.   68 Chapter 4:  The impact of war and displacement on traditional social protection strategies employed with young children.  4.1 Synopsis The previous chapter highlighted the traditional protection strategies that Acholi caregivers employed to physically protect their children and their perception of the impact that war and displacement had on their capacity to implement those strategies.  It demonstrated that the experience of war and displacement thwarted caregiver’s ability to mitigate risks to their children.  This led to serious and cumulative risks including violence, extreme poverty, malnutrition and infectious diseases.  This chapter will follow a similar format, focusing on traditional social protection strategies and illuminating the impact that war and displacement had on the socialization of young children.  The chapter has been delineated into two broad thematic areas that capture participants’ perspectives on the social strategies used to protect and nurture young children: 1) the ambient social environment and young children’s relationships, and 2) the teaching and mentoring of young children. It will follow the same three-part format used in Chapter three. First, each thematic area will be introduced through participant’s perceptions of the theme. Second, traditional pre-war rural agrarian conditions and experiences will be presented. Third, it will explore perceptions of war and displacement. As previously noted, this order of presentation allows for comparison and sheds light on the social mechanisms by which war and displacement impacted early childhood health and development.  4.2 Findings 4.2.1 The ambient social environment and a young child’s relationships The ambient social environment of early childhood …the Acholi say that 'the hooves of a cow that are behind follow the ones that are up front' …if the parent behaves badly, even the mindset of the child will be like that of the parents.  That means he has been watching your actions.  So it is important that a child learns what is necessary when it is not too late. -21-year-old father of two and caring for 1 additional child, member of the village health team This quote illustrates the Acholi belief that the social experiences children had, and/or witnessed (both positive and negative) were remembered, absorbed and emulated. The social environment a child lived in conveyed an impression of how life is supposed to be and  69 how people are expected to interact. The traditional practice of having children remain close to the home and surrounded by positive people who displayed respectful relations was therefore deemed important for providing children with solid foundations for the development of intelligence, character and interpersonal skills. What about living with people, how do you prepare a child to relate with people? With that one, I have noticed that the way I relate with people is what the child keeps on seeing.  And that is how she also lives with people because if you are living in a family with people, and you are so violent, yet you are a caregiver of a child, such a child will live in fear of people.  She will not get used to people.  But if you as a caregiver you live peacefully with people, with love, she will also live peacefully with people. She gets used to people then. - 16-year-old single mother of one infant, living in Pabo camp with her maternal kin Positive, cohesive and harmonious relationships between extended family allowed children to feel free and joyful. This was deemed true both for relations between spouses as well as relations within the broader social network of kin. Furthermore, working together, sharing responsibilities, and planning for the future strengthened families and helped them meet children’s needs. …if the father and the mother unite in the home and they are staying and living well in peace, things (resources) will start to be there, the child will also live in peace. – 33-year-old mother of 7 (5 biological and 2 step children), widowed by husband who was killed in the war and then inherited by husband’s brother A young child’s relationships Many participants in the study spoke of children’s need for love, attention and positive interaction. Young children were reported to need close family and friends to spend time with, relate closely with, and learn from. They needed to be treated with friendliness, and have caregivers demonstrate love through their actions.  For instance, carrying children on their back; soothing and comforting; responding to the needs of a child who is wet, hungry or cold; sitting with a child, talking to them and looking into the eyes of a child; smiling, singing, playing and laughing with a child; and providing snacks and treats. Such actions helped children grow and to be happy, intelligent, free, and peaceful. Participants concurred that loved children would grow healthily and without worries. It would put children on the right track to have successful futures and to be helpful to their families. …if the child experiences enough love in the family, that child will also be happy, he will also grow with love. - 50-year-old married father of 6, returned to the village this year after a dozen years in a displacement camp When you carry the child, he feels loved. … Children don’t want you to abandon them.  They want you to stay with them in one place and all the time.  Like me and our children, they want me all the time to remain with them in one place.  When I go  70 to the garden, I have to go with them. – 15-year-old male caring for 4 young children with his elder sister in a camp after their mother passed away The relationship between mother (primary female caregiver) and child was deemed to be critical during infancy.  It was seen as important for the happiness of the child and for learning skills and become a bright child. Although other categories of caregiver such as father, lapidi and grandmothers were also reported to be important, participants mentioned the child-mother relationship more frequently than any others. …. when the child's mother is dead, people also come to know that this child will not grow well. This is because he will be lacking love.  In order for him to grow he needs enough love.  When the mother is near he can put the head on the mother’s lap.  But when the mother is not there to do that for him he will grow as an orphan because a child of three years and below at all times he needs to wrap himself on his mother’s body, so when the mother is not there he will become lonely as an orphan. -25-year- old man, Rwot Kweri (traditional chief) Participants also noted a number of repercussions when social networks did not provide children with attentive care, or were neglectful. Those associated with unmet physical needs were the most obvious.  However neglect was reported to be a major cause of risk and suffering in many ways.  Mentally and emotionally, it was linked to sorrow, withdrawal, fear, negative thinking that could destroy the mind or create instability, poor concentration because of heartache or worry, and/or growing with hatred or bitterness towards the neglectful caregiver. Neglect could also lead children to develop socially undesirable behaviours as a means of survival, such as stealing and/or becoming greedy due to deprivation. …when and if there is no adequate care for the child, the body and the mind will not be able to grow well because the appropriate way of taking care of a human being has not been done to him at the level it ought to be.  –54-year-old father of 6 living in a village in Anaka Sub County after 11 years in displacement  4.2.2 The social structure of the village Participants remembered that in the past, relatives surrounded mothers and children. Elders were highly respected and the elder man of a home would generally be the household authority. As such he was responsible for ensuring that family life ran smoothly, including solving issues as they arose and organizing the family’s work and responsibilities. Participants reported that for the most part, kin shared good relations, felt responsible for each other and exchanged material and other support. Children naturally developed the same qualities and values, especially since their homes were isolated and they had very little contact with outsiders.  71 In the past, relatives were real relatives.  If you would call one, this is the brother of my father, that person would be a real brother to your father and would be good to you. - FGD with fathers in Pabo Sub County Although directly caring for Acholi children was primarily the responsibility of adult female caregivers and lapidi (child babysitter), care giving was understood to be a shared communal responsibility. When mothers went to work on the agricultural lands surrounding the homestead, they could bring along their breastfeeding children by tying them on their backs and/or take breaks to return home in order to cook for and feed their children left in the homestead.  Mothers were generally accessible and were close enough to hear their children’s yells if something went amiss at home. Participants also noted that when adults of productive age were working in the fields or gardens, elder women and even elder men would stay home to do household chores and watch over the children. If children had lapidi, they would be responsible to provide direct care, play and developmental stimulation, but be under the supervision of adults. Furthermore, parents spent a lot of time with their children in the afternoon and evenings, when they were at home. The grandmother would always remain home because most of them were unable to dig much.  They would only go to weed the garden and so the grandmother would remain to supervise children, she would stop them when they were fighting, she would give them food to eat, she would make them happy with songs she sings.  She would make the children busy by making them dance.  You will come back from the garden, you will find the children well and happy and life was just easy for them. – 34-year-old married mother of 4, living in village, Amuru Sub County Spousal relationships were generally reported to be peaceful and marriages enduring and binding.  Marital dissolution that resulted in a parent leaving their spouse and children was very rare. The elder women in one focus group recounted how grandmothers acted as mediators in their son’s marriages.  For example, they intervened if their sons were mistreating or beating their wives to make it possible for wives to remain in the marriage. The Acholi family system was (is) patrilineal, so if a marriage did dissolve, the children were absorbed into the paternal kin.  If a man died, the care of his wife and children would fall to his relatives.  In some instances one of his male relatives would marry his widow to offer her children care and protection. Further, polygamy was/is an accepted practice among the Acholi, so it was not uncommon for a man to have multiple wives and children.  As previously indicated, extended kin members helped each other to meet the needs of children.  If there were excess harvest it would be shared amongst relatives. Kin members would take a sick child to hospital if parents were away or working and discipline a child who misbehaved as the need arose. They also exchanged advice on care practices.  If one had  72 or could acquire monetary resources, they would assist kin such as through funds to pay a child’s education.  Lastly, issues that affected the family were communally addressed and resolved.  4.2.3 Loss of the nurturing social environment/ breakdown of relations and supportive social structures in war and displacement When conflict struck the Acholi region, it drastically altered young children’s access to family members and thus to the rich, nurturing relational quality of their traditional environments. There were widespread reports of social breakdown in the camps which participants related to over-crowded conditions, poverty, violence, uncertainty and living amongst strangers of different clans.  The conditions of war and displacement led some to experience despair and idleness.  The social risks described under the individual headings that follow were identified by participants as threats to their youngest children’s well-being and development. Social breakdown and kin lost Many participants reported that war and displacement led to the loss of family members (e.g. spouses, grandparents, and uncles) who would have helped with childcare and been a source of familial support in their villages.  One of the primary sources of lost kin was when families were scattered as they settled in different camps or at the opposite ends of the same camps. So I see as if perhaps it was the life in the camp that possibly destroyed the relationship between kin.  Because when in the camp one brother would make his hut somewhere like that, then the other brother will have made his on the other side, then another one somewhere else, so we were quite separate and were living apart. We did not get time to live together, to convene and deliberate on issues because the homestead was not one…when we were in the camp, it was just as bad as if we were in a prison.  One could not be free. – 27-year-old man, member of the village health team, Anaka sub county Further, rebel forces abducted some family members and many died in both conflict related deaths and from disease (particularly HIV).  In other situations, caregivers abandoned their children to be raised by kin (as discussed later).  These scenarios left many young children orphaned (in the Ugandan context ‘orphan’ means a child who has lost one or both parents) or abandoned. While some institutions and/or children’s villages run by non-governmental organizations provided care and shelter to orphans, for the most part these children were absorbed by their extended families, or sometimes were left to be raised by an older sibling. Although the practice of adopting orphaned children into the paternal extended kin was a positive protective strategy in the past, families’ ability to care for additional children was  73 impeded in the social breakdown and resource deprivation of camps. The participants therefore consistently reported that orphans were a strain on the limited resources of families. Additionally, whether a child was abandoned or orphaned, both situations were noted to pose significant risk to young children physically, mentally, and emotionally. There was a song sung by young children experiencing this situation: “mother come back quickly, for I am hated”.  One day while in the field conducting an FGD, the team observed a despondent toddler singing this song as he played listlessly with a stick. Participants were asked about this situation and it was discovered his mother had left the child with the maternal grandmother.  These participants (and others) noted the void experienced by children when they lost their mothers.  They told of how such children carried the void into adulthood: “they keep on only worrying, hanging on to their dead mother’s name, there is no smooth life for them,” as more fully described by the following participants: Another thing that is a risk to development is when children become orphans.  Death and then also the disease of these days (HIV) made mothers and fathers of children die. Taking care of these children has become difficult because many people are not willing to add in more burden upon what they already have so because of this, these children suffer and it spoils their growth.  Even when relatives take over responsibility of taking care of these children, they don't do it well.  I have an example of a woman who lives near my home; she lets her biological children eat separately and then later makes her biological children share food with the orphans she is taking care of. This has made the life of these orphans very difficult. -FGD with Traditional Birth Attendants, Pabo Sub County  Those children left by their mothers in our hands, they often worry so much because their mothers left them.  Even if I care and love him well he does not feel it, he wants his true mother who gave birth to him.  But the mother is not there, she cannot come to care for him.  So that child’s life, say if you send him to do something he does not want to do it, he does not obey.  So bringing up my daughter’s children has turned out to be difficult for us, so difficult.  – 57-year-old widow caring for 4 of her daughter’s young children.  … a child must not be distanced from the parents.  To gain good health, they must be close with the parents, those young children. Then they will experience a healthy life because that love from the biological parent is different from the other kind of love offered by someone who is just caring – 58-year-old father of 8, husband of 2 More young children Participants commented on the increased fertility during displacement.  They considered this to be a manifestation of the social conditions in the camp. For example, early curfews which forced sexual partners indoors, increased instances of adultery, and people engaged in transactional or survival sex in order to earn money for food or other basic necessities.  The  74 consequent rise in birth rates made it even more difficult for impoverished caregivers to give children adequate care and attention: …we give birth in a crazy way just because of the war…Sometimes you are collected into the camps, there is nowhere to move, no energy, so your work is simply to make your wife pregnant.  There is no farming, for you, you just dig a little, sometimes you are even found in the garden (by fighting forces) and there you are killed -you remain there. That is what has been happening.  So you find that protecting our lives and the lives of our children became difficult; we lack enough food because we produce (give birth to) children and spread them out carelessly.  Paying for them in school will also defeat us because we keep on giving birth anyhow. - 34-year-old father of 6, lived 19 years in displacement camps An atmosphere of discord and violence Another factor impacting the care of children was the increased breakdown of spousal relationships and domestic violence within families during displacement. Participants viewed violence in a home as a serious risk to the well-being of young children. There were physical health impacts of violence reported such as weakness, illness, or even death. This was both from the exposure to violence and the experience of chaos in the home, which meant that children’s needs were not met consistently.  A particularly brutal example of this was a mother we spoke to in the camps.  Her husband had come home drunk and aggressive. When he did not find her home initially because she was out begging a relative for food for her hungry children, he beat, kicked and berated her upon her return.  We met her two days later, and from the injury she described, we suspected he had either broken or bruised her ribs (and we encouraged her to seek out care at the health centre nearby).  Because of this injury she could not go out to perform casual agricultural labour to bring in money and provide food for her already hungry and under nourished children, thus putting the children at further risk.  Participants stated that children who witnessed or were subjected to violence would experience feelings of unhappiness, sorrow, isolation, rejection, intimidation, threat, fear and worry (as children would continuously think about when it could happen again). Participants observed a range of behaviours in such children including silence and withdrawal (shrinking into themselves); being easily startled; crying and shaking; a loss of appetite; developing a distrust and dislike for the violent parent (usually identified as the father); and/or engaging in avoidance behaviours such as fleeing the home in fear when the violent parent’s voice was heard. Socially, children growing in violent homes were noted to live without freedom (were inhibited) and would not engage or play freely with peers or adults.  75 Ah, violence is also a hindrance in the development of the child and people are aware of it because all of the time the child will be afraid, he/she will not be a happy person and it also causes the child to become lonely like an orphan all the time.  Not only that but when the child is playing, he/she becomes withdrawn even when playing.  The child cannot talk with people most of the time.  When you call him, he/she will not be able to come because he knows that you will receive him with hostility.  The child becomes afraid everywhere, even in the school you will hear that he does not talk, that is because of fearing people.  He will think that everybody is hostile.  –55-year-old widowed Traditional Birth Attendant caring for 3 orphans  The participants stated that the fear related to the experience of violence, and living without peace and comfort in the home, impaired the functioning of a child’s brain.  They observed that some children exposed to violence became mentally disturbed or unstable, and/or had difficulty with concentration, memory and lowered intelligence. …being aggressive makes a child grow up with fear and when the child is fearful, a child's brain will not work well and then, such men also like using foul language and the children also end up learning such language. The children will now use that foul language to abuse other children and such children in the camp here, the children who are well behaved always avoid them and this can make their lives difficult because no one will want to play with them.  This I blame on such fathers who make the lives of their children difficult and this makes them not grow up to be good children.- FGD with Traditional Birth Attendants in Pabo Sub County  As the previous quote illustrates, the experience of violence was also linked to a child’s tendency to display outwardly hostile behaviours such as shouting, fighting or beating other children, violence towards animals, and/or obstinacy/ rebellion with adults in their lives. A child who adopted such violent behaviours could become isolated as others would start to avoid them. Further, some would desensitize to violence over time. … I would like to talk about what violence does to young children when a child is exposed to it.  Such a child will grow up violent towards other children, even in school, you will always find him or her hurting others or harming others and the people will always make comments that, 'that child is violent like the father or the mother'.  They say that because they might have seen you be violent towards the child; a child will grow up with that violent spirit in him or her and go with it wherever he or she goes. Such children who are exposed to violence, people should learn to know how to handle them. – FGD with elder women in Pabo Sub County  For a young child violence is the worst because he or she will not listen to teachings, I have seen it with the neighbours here.  There are some children that do not even listen at all, even if you talk to them.  Even if you talk to them gently, they do not hear it because they experience violence on them very early, while they were still young. Those children are now used to violence. So for them to hear, you must use violence, you must shout for them to hear you. You have to shout whatever you say  76 and when you have shouted you must even touch their bodies; then they will hear. They have become totally desensitized, so I have seen that violence is the worst thing for children.  And there is this issue of beating using sticks, the moment you have made the children get used to being beaten when they are just beaten, it is only when they are beaten that they can do anything at all, when you do not beat them they don't do anything.  There is one, maybe neighbouring us here.  Unless the mother beats him, he will not do anything.  So I have seen that the cane and other forms of violence are what are worst for children. - 16-year-old single mother of 1 living with her mother and siblings in a camp  When participants were asked about the long-term repercussions of exposure to violence, they said children might adopt the character of the violent parent and become hardened to violence, developing a bad heart.  The exposure to violence could lead them to believe that violence was normal and desirable.  They might play out maladaptive patterns in their own lives, for instance growing into adult men who beat their wives or children. The cycle of violence would thereby be perpetuated as the child grew “…into a bad person, a harsh/cruel or violent person, a dubious and mentally unstable person” (mother 009, Pabo camp).” Further, participants noted that children who were exposed to violence were more likely to leave home at a young age, engage in alcohol (mis)use, or become lonely, isolated adults. Ah, in my opinion, children should not be beaten so much.  If you beat them, then they will become bitter and feel like orphans because you are beating them so much, so they grow up when they continue with bitterness and when they become adults they will say that they (the caregivers) were making them suffer. -15-year-old man who cares for younger siblings on weekends and sometimes extended periods i.e. up to 3 months, when caregivers/elders have returned to village to do agriculture/ rebuild.  Living in a camp  …the major problem is actually ignorance, just as it has been said, ignorance, ignorance.  Because you find that if anything happens between a man and his wife, they imagine that the only means of solving such an issue is by means of fighting or quarrelling in very loud voices such that the children who are in the house keep on hearing those quarrels, they keep on hearing those quarrels such that they also grow with that habit of quarrelling.  They think that if any issue offends one then there must be a quarrel or people must fight.  That is sheer ignorance. - FGD with Local Leaders in Anaka Sub County Alcohol abuse As illustrated in the previous section, the consumption of alcohol was noted to be a contributing factor to social dysfunction, disharmony, domestic violence and parental withdrawal from families.  Participants stated that alcohol abuse was more common, particularly among men, after relocation to the camps.  In their view, this was because the  77 engagement in drinking (and gambling as well) was a coping mechanism to help people forget the situation, ease feelings of frustration redundancy and loss of control. …this life that was lived in the camp, at least in the lives of other parents, the way that I have observed it actually they have no more hope for life.  There is nothing really helpful or nothing good they hope to do.  They have nothing to do for the future it seems.  So they choose certain things like drinking and the like; they don't even think of going to the gardens. Those things that the wife has struggled to acquire, that are available, they go and sneak into the house and take them away to use them for drinking. – 31-year-old father of 6 living in a camp  Alcohol abuse had a severe impact on young children because it meant that the parent (usually the father) was absent from the home, leaving one already overburdened spouse responsible for all childcare and teaching. The parent who engaged in drinking was less likely to engage in productive work to earn food or money for the family and would spend what little money the family earned on alcohol.   The introduction of drunkenness to the home created chaos and made it more difficult for the sober parent to properly meet children’s needs (i.e. regular meal times).  Alcohol abuse could also change the drunken parent’s behaviour such that he (or she) used foul or abusive language, became violent, and or exhibited other symptoms of intoxication.  The following children’s song, which was created in camps, illustrates the impact of alcohol abuse on children. Are there songs sung to young children? Well yes there are songs of course 'father, please father, father have mercy, father, please father, when he goes and reaches the drinking place to buy alcohol, father have mercy, please father' That song is sung for children of what age? Well, children of this age (the small child on her lap) can even sing it.  If the father is a drunkard, then they have to sing for him. Who sings it? You the mother of the child may also sing it. 'Father please father' and then the child can also pick up the song 'father please forgive us, buy for us a pen, when we go to buy a pen, there is not money, but when you go to drink alcohol, you fill a bottle with three sachets of alcohol' – 20 year-old mother of 2  …like here in this centre, you will find that when a child is growing to become conscious of himself he keeps on watching and he begins to believe that people after all must keep on drinking alcohol day and night.  So that means that it is a good practice and staying idly without doing any work at all is actually the practice in this centre of the parents of these children.  So when they see this they think 'so that is life!  That is the way of life' and I believe that that will be a risk in children's lives. – FGD with Local Council Leaders, Anaka Sub County  78 Divorce, separation, and parental abandonment Participants reported higher rates of divorce, separation, and/or parents (particularly fathers) not contributing to children’s care during war and displacement.  The reasons cited for relationship breakdown were numerous, and many have thus far been discussed including the pervasive lack and desperation that drove people (particularly women) to seek relationships with partners who could provide for basic needs, the immense stress brought on by the circumstances of war and displacement that strained intimate relationships, the social re-organization that brought strangers together in camps, and the loss of cultural practices such as traditional courting strategies.   With relationship breakdown, came a greater occurrence of abandoning children to one spouse, usually the mother. But when mothers were unable to manage childcare on their own, the responsibility was often transferred to grandparents. Many of the grandparents in this study reported caring for their daughter’s children.  This practice was a significant variation from the past when children would be recognized and adopted by paternal kin. …The way I see it, this war has brought divorce, it is now on the rampage, there is no good life because in the past when people were living in the villages the level of divorce was not as high as it is now.  In the past the actual reason for divorce could be in the case of witchcraft you could be rejected, or because of laziness and others. But now, even if you work like an elephant you may have divorce in your home, your husband may send you away or abandon you with all the children and then again you rush over to another man who will not accept to feed your children because they belong to another man.  This has caused our lives to be difficult and it is because of the war. It has wasted people strength; even the strength to somehow feed (children). Besides a girl can go to a husband when she is only 13 years old and if the parents are ignorant they will not even accuse the man (of relations with a minor) but can a girl who is 13 years old manage a family?  She doesn't have the strength. When she goes she may spend only three years in the house, until the love that she went with into the home with evaporates and she may have even given birth in the process and now they have divorced and this is the effect of the war, the war brought this upon us.  Imagine myself, I have four children that I am feeding alone by myself…One person alone is not strong.  All of this is the impact of the war that has been brought; serious divorce, very serious divorce. – 29-year-old separated mother of 4, camp in Amuru Sub County  It is the war that brought it (children being abandoned with grandmothers) of course. Your child will accept some child (boy) and she conceives with him and then he rejects her.  But your child wants to continue with the men and the next time, he persuades her and makes her conceive with him and then again rejects her, then she carries the children and brings them to you.  So you find that we have plenty of children, so many that we cannot feed them because we are weak. -57-year-old widow caring for 4 of her daughter’s children   79 As the previous quotes indicate, in this traditionally communal culture based on subsistence agriculture it was consistently acknowledged that it was very difficult for a single caregiver to make a living and meet the children’s’ needs for sufficient food, medical attention and paying school fees. In addition, it meant having no one to share daily childcare responsibilities with, such as feeding, bathing, teaching and guiding. Well your ability can be exhausted because some things like digging (agriculture), since I am alone like this, my strength can be exhausted.  But when you are two as a couple, at least you will have enough strength for the children.  After all you will find that digging is not easy, it can suck up your energy and there is no fixed time for anyone's death, so when you are finished, the child will remain in the world alone and the child will remain to suffer. – 25-year-old widow caring for 3 of her own children plus a child of her deceased sister Survival-based neglect of children and a lack of care options As mentioned, parents and particularly primary female caregivers often had to leave their home in the camp in order to pursue means of supplementing meager food rations. The distances this required them to travel made it impossible for them to return home frequently to care for a child in need or provide food. Participants also consistently emphasized that many mothers could not or would not bring their children along (with the exception of very young breast feeding infants) when they went to work because they feared abduction and violence and/or the distance to travel was too great.  The most fortunate of families still had an elder to assist with childcare, but many did not. Lapidi (babysitters) were sometimes available, particularly amongst the poorest of families who could not afford the minimal fees required for their children to attend school.  However, families were desperate for their children to get an education because they believed it would give them a chance for a better future.  They therefore worked hard to pay primary (elementary) school fees for older children to attend.  School attendance was also required by local policy and was monitored and enforced in some camps. Consequently, it seems that the average age of the lapidi may have declined during war. Too frequently, participants reported that the youngest children were left amongst their peers during daytime hours or with “older” children who were 5 or 6 years old and had not yet started school.  The participants acknowledged that this resulted in a range of problems among young children, such as hunger, injury, accidents and exposure to negative behaviour. Yet, children also found ways to adapt, which will be covered in chapter 6. …. mothers who had children 3 years and below were very many.  They were sending the elder children to school and now, these ones who were three and below  80 would remain home.  The mother goes away to the garden, the young one remains alone at home, they leave children without even washing their faces, they leave them with cold food to eat and the children would eat the cold food and then stay the whole day without eating any food until their mothers return from the garden. - FGD with Traditional Birth Attendants  What occurs when children are in the care of other young children? That can cause very many problems, take the case of those children who are still quite young, too young to take care of their fellow children.  Sometimes they go off to play leaving that child abandoned and from where she is, she will not be aware of whatever happens to the child– 40-year-old father of 4, still living in displacement camp, Anaka  There are mothers who go away to the garden and leave their children alone without a caretaker, you will find such children when they have poo on their bodies and nobody minds about them, they sit and smear themselves with their poo and at times such children may not even be crawling, you will find them with swollen bodies, you find them with food near them with a lot of flies in it, such children don't live; they always die because their parents neglect them. - Approximately 40-year-old widowed mother of 5 living in a displacement camp in Pabo Sub County  Sometimes the very fellow child can pick a stick and beat the head severely causing a bad wound or can beat the head seriously while the adults are there in the garden and since they were left alone, there will be no report at all that you must get.  That one can also cause the loss of children's lives.  – 46-year-old separated father of 10 living in a village in Anaka Sub County  The children in the camps had greater freedom to move without supervision and autonomously engage in activities than they would have had in the past. However, according to participants they were less free because they could not play unrestricted in the tightly confined spaces of overcrowded camps.  Camp residents chased children away from their homes. They experienced and witnessed violence and fighting, particularly at the hands of fellow children.  Further, they had many worries such as hunger. The freedom and carelessness that characterized village life for Acholi children in the past were gone, as was illustrated by the following dialogue among sibling caregivers in a focus group: Facilitator- ... did you like living in camps? Chorus-  No Facilitator- Why did you not like living in the camp? Participant 3-  People are often beaten there. Facilitator- Who beat? Participant 3- it is normally those children in the camp. Facilitator- What other things did you not like about camp life?  81 Participant 2-  they used to chase us away from their homes whenever we would go to play.  A void in childcare occurred in the camps due to the breakdown of social networks that would have traditionally provided communal care and mitigated children’s risk of adverse experiences. Participants, particularly leaders, acknowledged that non-governmental organizations had established day care centers in the camps, but said they were limited in number and thus not scaled sufficiently to meet the demands of the population. For instance, none of the caregiver participants reported that their children had access to such resources.  Additionally, leaders reported that some of the centers that were implemented were subsequently funded inadequately, did not support the staff, were not properly monitored and eventually failed.  Some charged high fees that made them unattainable to the many who lived in the abject poverty of camps.  Nonetheless, leaders perceived these services (Childcare and nursery schools) to be of value and spoke of a number of benefits: children were fed, kept clean and prevented from experiencing accidents or injuries; negative behaviours were prevented or corrected; social interaction skills were taught and practiced; there were activities offered such as playing and singing; and children learned skills which helped them to prepare for school entry. The leaders further believed that accessing day care services eased the burden on caregivers. This is illustrated in the following quote by a 24-year-old Local Council Leader (grassroots government official) whose community was exposed to a short-lived international NGO day care: ...the good thing that I could see on the issue of the centre is that when the children were taken there, it would give the mothers the opportunity to go and do their own work in the villages without any doubts in their hearts and no fear for anything bad that might happen to the children because there were supervisors of those children that were there…this actually brought happiness to the parents, so that time and again the parents were able to work hard in the gardens and it also gave children the opportunity, since they used to get injuries when they remained at home.  The rate of getting wounds also went down, and also those vices that children used to go and get involved with such as beating people’s hens, beating people’s ducks, were not there…Because at the centre they would be singing, writing, putting things on their bodies, on their heads as they played games and we see the impact was very good. As such, if that thing had continued, at least the supervision of children would have been much easier, even if the war has spoiled people's lives, at least the impact of good life would be there in our children.    82 Culture shift to “mine first” As has been described, the Acholi were unable to maintain their traditional communal childcare practices in the camps.  Neighbours were not necessarily relatives and had different values and practices.   Some felt that acting for another’s child, could lead to fights or misunderstandings. Some reported that they began to fear the consequences of disciplining or assisting other people’s children in the camps: …in the past when children were left home and their parents were not there, a neighbour who was nearby would cook food and give some also to the children whose parents were not around, but these days, people cook food and they only eat with their own children.   Even when they see a neighbour’s child sick, to help give first aid, they cannot do it because if you make the mistake of giving medicine to another person’s child, should the sickness increase, they will say that you have poisoned that child, and yet, you were only trying to help. People now don't trust each other, but in the past we used to trust each other. Most people used to help each other’s children in the past. You would treat another person’s child like your own…– FGD with elder women in Pabo camp Several participants said that in displacement, even relatives no longer helped each other. Greed and mistrust seeped into the culture due to the pervasive scarcity of necessary resources. The traditional communal culture was somewhat diminished as people developed a “mine first” perspective which included the belief that they could not afford to care for other people’s children. This was emphasized by participants in Pabo camp, as shown by the following excerpts: This life has changed definitely, because even if you have a relative in the camp, even when he has got some things you may stay hungry by him without this help- this means it has changed…They no longer help/share; they have become greedy personally I must tell you that I do not have relatives since they do not help me. For me if I fail to find hired labour, I must stay without, I have nowhere else to get help. The practice of sharing food in the camp is not there, people have become greedy. ~50-year-old widowed, then separated, mother of 11, living in Pabo camp. Her children frequently went hungry …. You know, generally, a child or children in our community, we used to say that a child does not belong only to the one who delivers (gives birth to), actually it belongs to the community.  So the community is supposed to look after the children.  Well, these days it is reducing…in the past it used to be community, the community were much more involved, but these days they are pulling away. - Health worker in Pabo camp These quotes illustrate the shift away from shared care giving among the Acholi in the camps and the corresponding loss of a traditional child protection strategy that it entailed. Caregivers lamented this loss and the concurrent increased vulnerabilities of children who had fewer social resources to draw upon than they would have had in the past.  83 Caregiver stress and trauma The loss of traditional social supports, pervasive lack of resources, atmosphere of fear, and experiences of violence had profound impacts on caregivers themselves. Caregivers spoke of losing control over their lives and being oppressed by many environmental factors that inhibited or seriously reduced their ability to care for their children. Some expressed that the war had caused mental confusion and a sickness in the heart that could lead them to withdraw from their families or lose the ability or energy to teach and guide children. …because your ears are always tuned into this issue of death that is looming, you think of how they will come to abduct you and whatever they will do to you- you will have fear in your heart.  So because of that you don't even know how to speak to your child, because your ears are tuned, your heart is tuned to that impending suffering, your mind is always thinking of fleeing. –70-year-old widower, FGD with Anaka elder men Participant’s also expressed feelings of grief, pain, sorrow, unhappiness, and worry. Mental/ emotional health impacts were often described as manifesting in bodily symptoms such as heart problems, high blood pressure, ulcers, and heartburn, which weakened caregivers or impeded their ability to work and provide care. Some recounted how they simply just kept going and working despite their own pain, hunger, stress or lack because for the sake of their children, they had no other choice. Nonetheless, caregivers’ were highly stressed and weakened, which inevitably had an impact on the children. Every day the life was difficult.  This is why I said that life in the camp was hard, most of the time Lakwena (rebels) would be entering the camps and if you are the mother of a young child, you have young children, two, three, you will experience a difficult life.  Even your husband will run and abandon you with the children. Now with that, if it is young children, you must as the mother of the young child keep on struggling with the child.  So that is how difficult life was.  Then there was issue of feeding, what to eat? There was even nowhere to cultivate food.  – 27-year-old mother of 4, living with the children’s father  4.2.4 Teaching and mentoring young children Participants reported that the informal education children received through the teaching and mentoring of kin was critical preparation for a good life.  It allowed for the acquisition of important skills (livelihood, social-relational), attributes such as intelligence, the development of character and increased chance of success in the life course. …people say, 'you should never give up with a child, they are still young, when they are young they can still be bent like a stick that is just growing, it is only the matured trees that cannot be bent, but the young growing ones can still be made to grow straight'–42 year old mother living with her husband, adult daughter and granddaughter in their home land in a camp  84 Children were described as becoming “conscious” (i.e. developing awareness) of their surroundings and themselves as they developed from infancy. Caregivers would steer them in the right direction during this process.  To this end, the demonstration and repetition of new lessons was seen as very important when children were very young and easier to control. As children matured and mastered their lessons, adult guidance lessened. Accordingly, for young children good teaching required caregivers to be near and to spend time with children so as to observe, instruct and correct when something was done wrong. In teaching young children, caregivers and elders tended to focus on respectful social behaviour, moral instruction on the delineations between good and bad, and the acquisition of new knowledge and skills. Taking care of the child well is when I begin telling the child that you should not do this, if you want to do this (have a bowel movement), you get up and go and do it there. You talk while showing the child what to do.  So talking repeatedly may help the child. - 37-year-old mother of 6 still living in a camp  If it is a child who knows himself (mature) you don't teach him every day.  If you tell him 'this thing is wrong, he might still commit that offence but at least after he has taken some good time without doing it, for instance, after a week they may fall into that problem again.  But if it is one quite young, he will be offending everyday and you must keep on telling him every moment that 'this thing is wrong, this thing is wrong' you must keep on telling him. – 68-year-old married grandmother caring for her 4 grandchildren under the age of 6 after their mother abandoned them with her to elope with a man Instilling discipline and respect in children was seen as fundamental in traditional Acholi culture.   The Acholi believed that it was important for children to learn to listen, memorize and follow teachings without talking back disrespectfully. Children who listened well, were obedient, respectful, disciplined, and who worked hard and were helpful were felt to be intelligent. They were seen as having the potential to become respectful, loving adults who would be thought well of in the community and deserving of the blessings bestowed by the elders. They would also be primed for success such as doing well in school and life, prepared for a good future with solid social relations. What could prevent a child from becoming as successful as possible? It is all caused by the same problem, that is, being obstinate; it is the one that can make a child not have a successful future.  – Married mother of 6 living in their village in Anaka Sub County after approximately 13 years in displacement For some caregivers, talking was the main means of teaching discipline and correcting children.  For example, they would repeat the same lesson, talk in a stern voice until a child understood and/or offer praise for positive behaviour. For others, it was deemed essential to  85 use corporal punishment such as beating or caning, or the threat of such punishment. However, physical punishment was generally not used to discipline infants or very young children who had not yet developed ‘consciousness’ (i.e. did not understand right from wrong).  Rather, it was seen as appropriate for children who would not listen when given a verbal correction that they could understand. Physical punishment was reported to be effective in helping children remember the lessons, and ensure they did not repeat the problematic behaviours.  It was also reported to curb obstinacy and ensure that the children matured having learned the necessary skills and lesson.  The following quotes illustrate the participant’s range of perceptions on disciplinary measures for young children. We should avoid shouting at children and even our elders used to say that 'if you have to teach a child, don't shout at the child, talk well to the child.  If you are always shouting at a child, your child may become like a fierce dog and always fierce dogs bite the ones who feed them'. - Elder women FGD, Pabo camp  I and the father should help the child by telling the child that 'don't do this' and if the child listens then it is good, and if the child does not listen, you beat and the head will begin working well.  – Approximately 30-year-old mother of 4 living with her spouse between camp and village in Amuru sub-county as they transition post-war  …when the child is still young and is saying 'stupid' then you pinch their lips painfully and look at him or her very sternly and the child will not continue to insult.  But if a child insults people and you just ignore it or laugh as the child keeps on insulting then such a child will get used to such things.  The child will begin to know that 'it seems this is a good thing'…. For me if it is still a young child who does not listen to what I say, does not listen to my words, I speak to them and they do not listen, I must beat that one…. But if you make people too used to violence, serious violence all of the time on them, then the child will become obstinate for good.  So much so that they will not listen to you. - 70-year-old widowed mother caring for 4 of her grandchildren left with her by their mother who remarried elsewhere  These quotes touch upon the physical violence, which was previously described and commented upon.  Even for participants who condoned corporeal punishment there was a line where physical violence was recognized as being detrimental to the child on multiple levels and not effective as a means of teaching.  4.2.5 Teaching and mentoring in the village What could prevent a child from becoming as successful as possible? The things that could prevent a child is if both parents are not there.  That one can actually destroy the future of that child because he will not get any appropriate teaching in his life.  It will not be there.  – 31-year-old father of 6 living in a camp in Anaka Sub County after 13 years in displacement As a part of daily life in the village setting, children were taught many lessons to mould them  86 into disciplined people with strong prospects for the future. The family determined the nature of these teachings and caregivers used a range of methods, including enticements, verbal instructions, demonstrations of behaviour, and talking at the evening fire (wangoo).  All members of the family could assist in correcting, and even adult members of the community could stop a child from a transgression if the immediate family was not around. How a child is trained in discipline, this is what I know: In the beginning first of all it is done by the child’s mother….  As it continues, as the child continues growing, we fathers begin to also give them some help in training the child in discipline… the child may reach the age of three, you can begin to tell the child how he must live or how he must respect people because if you send him on an errand and the child just goes on his own way, that child is not learning discipline, that means, he needs training seriously.  That (training) is: to go and bring something, go and greet somebody, go and pick up such things that he can pick up, that is how you train in this way -it is needed because the child will learn to help people. - 25-year-old father of 3, husband of two wives, living in a transition camp for 4 years, 13 years in displacement The children lived within and according to the environment of family and thus were easily controlled. Many of the participants commented that the children in the village listened, showed respect, and were teachable. Physical and harsh verbal punishments were therefore rare and generally used only as a last resort. But at home there was no caning/beating because children were obedient and respected adults’ words...It was easy to guide them you train a child to follow your words - no stick was carelessly used.  Disobedient children who needed to have words repeatedly told them, were those beaten. Parents used merely to talk with their children. - ~40 year old widowed mother of 4, caring for young niece in Pabo camp Teaching and mentoring in productive roles were fundamental to the Acholi’s rural agrarian society. Beginning in the second to third year, children were given small chores in the household and gardens.  This helped them learn to be helpful, hard workers and develop stamina, physical strength and skills/abilities with which to contribute to productive pursuits in their homes and prepare them for the future. Tasks assigned to a young child who had limited skill and comprehension, were kept simple.  These tasks became more complex as children increased in age and experience.  For instance a young child may be asked to bring a household item to a parent, or fill a cup with water from the pot and deliver it. … because the child has grown well while in its infancy, he will be able to help the adults because he will have learnt those small things in his development such as digging (cultivation), hard work.  Because you see, a child's brain is like a computer. When he learns things in bits and pieces, he memorizes it and it gets stuck in the brain, so when he has grown into an adult he will do exactly what he learned while he was still young. –30-year-old Rwot Kweri from a village in Amuru Sub County Sibling caregivers also talked of how they would include children in daily activities that  87 contributed to family life (e.g. giving them a tiny jerry can so they could come along to fetch water or letting them help do washing).  This gave the younger children opportunities to practice and develop skills (figure 3).  Figure 3: 3-year-old girl practices using and carrying a hoe.  For a child to have a successful future the first thing is your child should not be lazy; your child should be a hard-working child.   If you train your child well, your child will not be lazy, you can do this through taking the child to the garden, always telling the child to help you with work at home, and when you do this, your child will learn to work hard and will work hard for his future.  If you as a parent are lazy, you will also be a bad example to the child and your child will not have a successful future.  A child should first look at hard work as the first thing in life…-FGD Elder women, camp in Pabo Sub County  In the evenings when the work was done, families would convene at the wangoo (campfire) to pass time together. At wangoo all would share nourishment and Acholi elders delivered teachings: Facilitator- What were the benefits of Wangoo for young children? For the family? Participant 1-  Giving lessons to young children when you are at the evening fire, you can teach them if the children sit close to you, you can teach them. Participant 3-  You can give them the 'ongon' (codes of practice). Participant 7- The teachings of the past. Participant 5- You give Ongon, it is very good for young children. Participant 7- For a child whose parents are not there (orphaned), he also will go and squat in this manner by the grain store while you have gathered  88 around the evening fire, so the teachings that you are giving to your children, that child will also be able to hear them…Orphans, the evening fire is there for taking care of orphans.  It is also a good place for discussing traditional issues.  Every issue is listened to at the evening fire.  The families sit and gather around, all proverbs are shared for teaching the family so these are issues brought up around the evening fire.  -FGD with elder women  These teachings received at the wangoo were believed to help protect children by providing lessons on topics that prepared them well for life.  The lessons included topics such as the value of working hard; the benefits of studying; and the importance of filling the granaries with food.  They also passed on Acholi traditions, language and important values such as to live well with others, to pray to God and fear God, and not to fight or steal. Children were disciplined if they had committed a wrong during the day.  The wrong would be explained and children would be warned not to repeat it.  Conversely, children who had behaved well during the day would be praised and used as an example of correct behaviour. Most of the educating of the children was done at the wangoo and they would talk to all children.  They would talk to all children, even when only one children had done something bad during the day and then after talking to all, they would warn the child who did something bad during the day and children were very obedient and then would listen.  They would not repeat the mistake they had made before.  – 34-year- old married mother of 4, village, Amuru Sub County  Traditional lessons and entertainment was also delivered through folk tales, proverbs, songs and riddles. Riddles were fun brainteasers and a particular favourite among young children was: “what goes bingilie, bingilie?” Answer: “the tail of a sheep!” Proverbs and folk tales usually highlighted desirable characteristics or manners, as is illustrated by the following excerpts from a FGD among fathers in Anaka: Participant 1-  …you tell him that ‘a hyperactive goat breaks his bones beside the granary'. Because you don't listen to instructions, you keep on behaving mischievously, so you can tell him there was a certain goat jumping carelessly at the side of the granary, and it got a fracture - that will be you! So you also tell the young child this so that the child will fear. Participant 6-  And there are others like this, 'the monkey that remains behind laughs at the tail of the front one', that is because he isn't seeing his own tail, that means you are actually walking with your friend but you are laughing at him because you are not aware of your own problems.  You never know you could also be having the same problems as that one! Participant 5- Like for example, children say if the friends clothes get torn, they many not recognize that theirs is also torn in the back, so he laughs  89 at his friend pointing out his friend to the other that they are with saying look at the back of that ones' shorts!' and yet his might also be like that, so that is why it is said is that the monkey at the back laughs at his fellow monkey's tail because he is not looking at his own back…  Children would sometimes play by the side of the fire, particularly when the moon was bright. Even if the young ones did not fully understand what the elders talked of at the wangoo, being present helped them begin to acquire the teachings as well as gradually increase proficiency in the Acholi language. The wangoo united families. Children came to know their living kin and through the talk they also knew their ancestors and the history of their people. …the evening fire first of all forges unity, secondly, it brings to knowledge, what other people did not know, they will know it.  For instance the children, sometimes the children will not know their fellow children, but when they sit at the evening fire, those ones sit in unity and they get to know one another.   And it also allows for accomplishing what should be done together… I tell my brother the problems at hand and my brother will also be there saying 'let us do this thing like this or how can we do it?' so things get organized …  So that is what it means to have the evening fire. It is important. – 45-year-old husband of 1, father of 6, Anaka As illustrated in the last quote family would also use time at the wangoo to plan out how to manage tasks that needed to be done, or items that needed to be paid for or procured.  If there were issues such as disagreements, these would be discussed. If breaches of proper conduct of social codes were not too serious, they could also be dealt with at the wangoo amongst the family. All of the above teaching and mentoring factors forged a harmonious social environment that facilitated optimal learning and met children’s needs in a holistic manner.  4.2.6 Teaching and mentoring during war and displacement Teachings, traditions and culture lost Participants said that families were unable to provide young children with many traditional teaching practices during the years of war and displacement. The wangoo was not possible in the camps because kin were no longer together, firewood was extremely difficult to acquire, and there were often nightly curfews. The venue and network for the sharing of folktales and proverbs were therefore gone and the teaching previously provided through daily social interactions was largely absent, as children were frequently unsupervised. Caregivers didn’t have the time with their children that they would have had in the past, which allowed them to provide close monitoring, corrections and guidance. It was difficult to  90 pass cultural traditions on to children or teach them the agricultural and livestock husbandry skills that were seen as vital to their futures.  Due to the ever presence of danger, people were reluctant to take children with them when they went to work on the lands, which denied them the opportunity to watch, emulate and learn traditional means of livelihood. Children have not had the chance to learn traditions like making granaries, digging and making houses, children were not being taken to gardens for fear of abduction by Kony rebels… the parent is always in the garden, no time to teach children..- 27- year-old married mother of 1 Several of the younger participants reported that they were unaware of how people lived before war, as they were too young to remember and had not been told.  Others had heard about the past, but lacked first- hand experience of traditional Acholi village life. At the same time, new social practices were created and experienced.  For example, instead of engaging in traditional games and dances, children observed and learned disco dancing. Shift in the source of social teachings Caregiver’s accounts suggest that they felt that they lost control over the monitoring, teaching and disciplining young children in the camps.  Participants reported that caregivers did not know what went on in the lives of their children much of the time, particularly once children were ambulatory and entered the peer group. Children would not remain close to their camp homes but would wander, the infants tied on the backs of the older children. They reported that children no longer listened, disappeared when parents tried to give them education or guidance, and did not come when called. … Children could stay for a long period of time without receiving any teachings. There was nothing that children were listening to except the talk of fighting only. Children beginning from three years old, when you speak to such a child either at home here or in the compound, they would go out and begin to do the opposite.  For that reason the children that we were living with in the camp ended up growing badly... – 36-year-old Rwot Kweri in FGD, Anaka Children talked back, argued and were uncooperative, aggressive at times.  Some caregivers reported that they increasingly resorted to using physical punishment in order correct children’s behaviour and attitudes.  Many felt, however, that this was pointless because children could not be properly guided as long as they were in camps. Additionally, a few caregivers spoke of the unhappiness, stress and pressure they felt as they tried to care for children in the camp environment and noted that this made them less tolerant of children who disobeyed or acted carelessly. We were teaching our children to be good children, to live well but a child could move out to the midst of the camp and find some other teaching from there and for sure, children were really obstinate, a child does not listen to you. And even when  91 you want to teach them you would not be there at that particular time because you would be searching for a means of survival, something to live on…Because of the problems that were happening, there was unhappiness, it was there.  So I became bitter, I used to be angry with the children if they did not perform those duties that I wanted them to.  Then at certain times when I would come to the garden I would find when the government had closed off the way saying 'today there is no going to the garden at all, everyone go back to the camps because the security situation is bad' so sometimes you would go back to the camp without reaching the garden to collect some food.  Then again you may find when the children have left the flour for making bread to be eaten by the goats, such things would cause me such pain in my heart, I would be bitter and I would really beat them seriously ... – mother of 6 living with her husband in their village The new teachers of Acholi children: strangers, peers, and media When children wandered in the camps they were exposed to many different people (both adults and peers) and to teachings that caregivers thought had a bad influence them.   They had ample opportunity to witness behaviour or media which were considered to be negative or inappropriate and violated traditional norms (using foul language, fighting, skipping school, disobedience, defiance, stealing, drunkenness, provocative dancing, and culturally inappropriate dressing). The camps also introduced them to bars, discos, and movie halls, which fascinated them.  They often crowd around these entertainment venues to peek inside, which might expose them to videos with sexual or violent content. …children went into the camps, people came together, they encountered those with bad characters, those with sharp tongues were there; even when in your own home you are not someone given to insulting people you are not sharp tongued.  In your home if you are not foul mouthed your child will also not be foul mouthed because the child follows after the mothers actions.  On reaching the camp however you would go and find drunkards who were there, the stupid ones are also there and what have you.  Careless talk, insults, careless talking, so it causes fighting, even against the child.  If it is a young child like this one, should you start beating him, he will immediately insult you with any kind of words, anything. And all this we blame on the war.  That is what I have witnessed.  – 20-year-old mother of two, caring for sister in laws 2 children as well The variety of people in the camps provided an additional source of intrigue, and they would run at the sound of cars to see foreigners that may be arriving. Traditional strategies, which taught children humility and respect for adults, were thus being compromised: In the past, if you were a visitor in a particular home, children do not come and stand by you just like that or even stand over you. They may stand from afar and they would also show respect.  Today however, if they hear the sound of a vehicle, of one motor vehicle alone, then the whole place will be full to the brim with children only. Just coming to see, they stare, they come and stare, even those ones whose bodies are full of dirt.  Even those who can hardly crawl, they will be struggling to crawl over just to come and see with their eyes.  Our children are growing when they are not humble, even the little child also if he hears the motorbike ‘brrrrrrr’ the ears would  92 standing alert, concentrating there, they don’t want to make any noise to miss it. Then they come and gather around the motorbike. Children here have defeated us, you cannot control them. That is what I have observed. – 41-year-old father of 11, husband of 4, 15 years lived in camps Lost control and child rights As the participants recognized that children watch, absorb and emulate what they see, they understood that exposure to negative social influences would have negative behavioural outcomes. Caregivers were seriously dismayed by the camps’ social influence on children, which led them to become disobedient, disrespectful, stubborn and idle. They were tremendously worried about the disappearance of traditional Acholi values and norms the younger generation.  Many felt that the camps had damaged their children’s minds and manners, which put them at risk for problems in the future.  This is illustrated by the following excerpt from a 56-year-old father caring for 6 children, including 3 grandchildren: …the camp has made children become careless with their lives.  If a child watches something bad, he will also want to adopt it; in that way it is important to have an environment where a child can be trained or taught properly because when a child is of that age, you can tell the child and teach him that this is bad "owaa" (dangerous), don't pick it up, so the child can understand.   However in the camp you would find that a fellow child is teaching the other 'pick this thing up here, do this thing here' so you find that children are doing things which are not proper.  Even something bad, a fellow child will teach the other to do it and because he is small, he will not know that it is a bad thing or it is good.  That is why it is very difficult to train a child in the camp…. The problem with camps is also like this. It has turned many children in to thieves because the friend will tell him 'look at that biscuit' and if you the mother have forgotten to take care of your money, that companion of your child who knows the way of biscuits will say 'my friend, that money of your mothers, why don't you take it so that we can buy biscuits and we eat'. He will say 'my friend, mother will beat me'. Then he will say 'no, your mother will not know, how can she know?' Then the child begins to take money to buys biscuits.  You find very little children go to buy things in the market, and they know the value of money.  In the village, children did not know money even though you left it somewhere in the open, nobody takes it; it is you who goes to the market somewhere, then you buy and you bring the biscuits back with you to distribute to them... children know that beans, there is value of money in beans and the buyers cannot know that this child has stolen the beans.  He will be happy for the child to bring beans, even if it is just 2 cups of beans, or even 3 and he gives money for the beans and the child goes to buy things with it… in the camp he will see the friends eating and will want and to be comparable to the friend, he will also want.  That is why children are getting spoilt [ruined]. Many participants made similar comments about the social environments of camps spoiling or ruining their children. Caregivers didn’t know how to regain control, especially since the children’s rights education delivered in camps forbid the physical punishment of their children.  While some participants thought this was a valued lesson, a number of participants expressed that it further thwarted their ability to correct and discipline their  93 children by disallowing an intervention that helped the children grow up to be good adults. When asked about alternatives to physical punishment, many spoke of talking to children but had few other strategies. An additional impediment to disciplining their children was that when they tried to do so, others in the camp would interfere or other children would gather around to observe the event as if it were entertainment. Several participants reported that these situations left them feeling disempowered in terms of their ability to influence teach children. … it is not acceptable anymore for a child to be beaten. Yes. Because it is said that children also have their rights, the moment you have beaten a child, that will have become a crime already. - 31-year-old father to 6, camp in Anaka Positive teaching acquired in camps It is salient to note that some of the beliefs, attitudes, knowledge and practices that children gained due to the war and displacement were seen as positive.  Participants frequently reported the increased value placed on formal education. As more people were displaced into the camps, over time, more schools were established to educate the children. These included increased awareness among leaders of daycares and nurseries, which began education early and provided children with a safe place to be cared for when their caregivers were working. Parents were given education sessions about the value of school and policies were put in place to penalize families who did not send their school-aged children to school. Gradually and informally, people simply began to witness the benefits of education.  They saw the knowledge their children were gaining, witnessed the positive outcomes of education when neighbours’ children who had attended school became employed, and had much more exposure to educated adults (i.e. health care workers, teachers, and NGO representatives delivering aid).  The participants who had been exposed to early childhood education realized that preparing children for primary school would give them an advantage. In general, participants reported that their level of interest in education increased dramatically and felt that schooling was one positive aspect of camp life, which boded well for children’s futures. …. most parents have seen the advantages of taking children to school. Going to school removes away ignorance.  Most parents who did not have the chance to go to school all worry about their children's education.   Most people have put taking children to school as number one in their priorities- 21-year-old married mother of 1 young child, recently returned to their village in the Amuru sub county  However, a quandary emerged for many – as the value placed on education grew, poverty also intensified over time making it more difficult for caregivers to afford the costs of  94 education, even if it was very low fees for primary, or the cost of uniforms, books.  Several other positive shifts occurred during the time of war and displacement.  First, some participants reported that families became more likely to see the value in girls beyond bride price. Caregivers recognized that the education of girls would enable them to help provide for families and improve their life prospects. These factors improved life prospects for girl children. Second, participants consistently commended a financial practice they had learned in the camps that was called “bol chup” - a savings and loans practice. According to this practice, people (usually women) would work in groups and each member would regularly contribute money into a box for safekeeping.  Although the money deposited was small, it would accumulate over time and be used for emergencies like taking a sick child to hospital, buying food or clothes, or giving members loans to start businesses.  This practice opened doors to opportunities not otherwise available in the camps’ impoverished environment and participants felt it built on traditional values of trust and reinforced Acholi taboos against theft. …mothers, they do not only have to work, they also have a certain kind of thing that they call bol chup.  This thing, they know that if you are in the house alone, if you must keep on saving money, say 100 or 200 each day, it is not possible, so for them they form groups and they follow a stipulated day, one they have decided on, then they go and they deposit money there (in a box).  They drop their money there. Then when the time comes for counting, then they open that box of theirs and you will find that they will have saved some good amount of money, enough for buying uniforms for the children, enough for buying books and other things, even enough to pay them in school.  It can bring a transformation in the home because they even buy certain things for the home.  But if it were that each person should individually pool money, you cannot save your money, say 10000 in the house, you will have spent it. So I see that that is one of their struggles, they group themselves up and that is why they are helping the children. They are actually ensuring that children are being cared for well.  – FGD with Local Leaders, Anaka Sub County  Lastly, participants reported that they found it useful to learn how to keep written records of properties, land holdings, and wills.  This deviated from traditional Acholi oral culture in which elders played a key role in the determination of ownership and the boundaries of commodities such as land.  However, participants appreciated that written records could protect families and ensure the inheritance rights of children in the future. As will be shown, this was particularly salient in the post-conflict period when land disputes were rampant.  95 Chapter 5:  Risks to early childhood health and development in the post conflict transition of northern Uganda  5.1 Synopsis An estimated 90% of the northern population lived in displacement by the end of war and consequently, the majority of children in the region were born and raised in camps. While issues of innumeracy made it difficult to quantify the exact number of years participants spent in displacement, most reported living in camps for more than a decade. After such a prolonged period of restricted living, the move back to rural agrarian villages was a major transition that took time and impacted all facets of life; still, it was welcomed.  All participants indicated a desire to get children out of camps, and away from the numerous threats to their health, safety and well-being. These included overcrowded conditions where disease spread readily, the under-nutrition arising from lost livelihood, and the uncontrolled exposure to negative social influences such as violence and alcoholism.  This research purposefully sampled families in various phases of post-conflict transition in order to capture and understand the experiences and environments of young children across resettlement. The findings have been grouped into four sections which will outline broad themes corresponding to children’s environments during transition: 1) the physical environment, 2) the socioeconomic environment, 3) the social (care-giving) environment, 4) the regional resource and service environments.  5.2 Findings 5.2.1 The physical environment and process of transition This section highlights themes relating to the physical process of transition that occurred following the end of the conflict when families began to move back to rural villages.  The major sub-themes in this data were: 1) the caregivers’ focus on physical rebuilding of home and livelihood, and 2) vulnerable families without land and social support. Focus on rebuilding After prolonged displacement, the move back to former homesteads was reported to be deeply challenging for caregivers.  Rural village homes traditionally constructed of baked bricks and grass thatch roofs had long since disintegrated and had to be re-built from  96 nothing along with structures like bathing shelters, latrines, and wells.  For many, the agricultural lands had gone fallow, which meant significant periods of time and heavy and prolonged labour was required to clear, plant and re-establish crops needed to feed the family.  Furthermore, belongings, while usually minimal, had to be transported gradually from the camps, usually carried on people’s heads or, less frequently, with a bicycle or hired motorbike.   These grueling activities of re-settlement had to be prioritized in order to re- build homes and livelihoods.  However while caregivers worked, young children could not live in remote and wild regions without shelter, food, and services such as health care. Consequently, both caregivers and leaders reported that children were being left in camps while adult family members moved back and forth to the village to complete the necessary work (discussed further in social-cultural environment section). I am living in the camp but not fully.  I have one leg here and one leg in the village….We have homes (villages) which are very far, some of our homes are more than 10 miles away from here and you cannot gather your things all at the same time to return to the village.  I am picking my things one by one and if I was to go at once, life may not be easy for me there because I have just cleared my gardens (agricultural land).  My children may lack food to eat when I take them there so I have been leaving my children behind.  My wife, and I we have been going back home to build our huts and to clear gardens and to get a proper water source for drinking. With the house also I have just made the bricks, I don't only need one hut, I need many huts because I have children.  I have only planted potatoes there.  When I have planted enough crops, and they are ready for harvest, that is when I will be fully in my village, but right now I am not yet ready. Some of the crops I planted were destroyed by sunshine. - Father in FGD held in a camp Without land and support While most families encountered in camps were in the process of re-building and re-settling, in each camp studied, there were families who were unable to return to their homes and agricultural lands despite their desire to do so. In Acholi culture, married women moved to their husband’s land and men possessed many of the skills essential to building homesteads such as constructing structures and clearing fields.  Consequently, female or child headed households, elders, people with disabilities or weaknesses, and other categories of caregivers who had limited social support (because male relatives had died, abandoned, were abducted or lived distantly), often spoke of being without return options. This included being without access to land that would traditionally have housed and fed their families, and/or having no one to help them rebuild. Left in the limbo of camps that were emptying and closing, they spoke of great strain in trying to meet their children’s most basic needs.   97 …. it must be the one who has nobody to help them build a hut who has remained in the camp.  The owners of these lands (camps) also want their land to be vacated but now you will find that people have nowhere to go and you are quite confused… - 29- year-old separated mother of 4, still living in displacement camp.  Well, for me, this war has brought me loss.  My husband died, the father of my children.  I have remained with children, with no one to help them.  Even I don't have any means of taking care of them, it has become very difficult; sorrow almost killed me.  I would keep on remaining silent and I became sick.  My chest would pain me. There is no one who helps me with the children.  Even trying to get a means of living is extremely difficult. – ~40-year-old widowed mother of 5, still living in a camp  Furthermore, in each camp families were encountered who attempted to begin the process of re-settlement only to be stopped by land disputes with kin. Such disputes drove them away from land they felt they had claim to and left them with limited means of providing for young children in their care.  These disputes also caused rifts between kin who in the past would have been a source of social support for children providing assistance such as childcare, advice, and/or material resources. … the conflicts over land are so intense.  People are coming back alright, but they have become enemies.  People are coming back but there are too many; they ran away from the war, they went and multiplied so much, they came back with their young children.  …. It is because of land that people have become enemies.  It is as if they are no longer relatives… One family; they disputed over land; they beat each other; they fought with hoes when they were digging in the garden; even with spears… –20-year-old mother, living with her husband and 4 children (2 biological, 2 of kin) in their return village  5.2.2 The socioeconomic environment of children in post conflict This section illustrates themes relating to the socioeconomic environment of young children during post- conflict transition.  The major sub-themes are: 1) The cessation of wartime subsistence, 2) The origins and experience of poverty after war, 3) Young children’s unmet needs, 4) Hard work, poverty reduction approaches and persistence for a better future. The cessation of wartime subsistence In camps, provisions provided by governmental, non-governmental and international organizations had attempted to meet children’s basic needs (reports suggested major gaps as covered in chapter 3).  However, when war ended and there was a call to return home, a substantial portion of war-time subsistence ceased.  Many of the provisions that had been supplied to some extent in camps such as food, basic household necessities and clean  98 water were stopped or reduced to particular populations. This increased vulnerability of children whose families had not yet made a transition from economic and nutritional dependence to independence. When aid stopped, independence had be gained rapidly and almost exclusively through pursuit of productive occupations (primarily agricultural pursuits). Yet as the previous section described, the resumption of livelihoods was not quick or easy. It is hard to get food for my family because it is hardly there. Because I do not have a garden (agricultural lands), it is hard to get it. I have to do piecemeal work or hired labour in other peoples' garden if I have to eat, if I do not do paid labour, we have to go hungry - with nothing to eat…. The most difficult is this year; it is too much for me. At least last year, people were in the camps we were doing hired labour. We were getting food to eat from them (aid agencies), but now, they are no longer there at all. For us who have remained (in camps), there is no food to eat; this is the worst year of all. – Single mother (one time widowed, one time separated) caring for 11 children while remaining living in a camp with her elderly mother  After the war life still continued to be difficult for parents because of food.  Because when the conflict ended WFP (World Food Programme) also stopped giving out food so getting food for children became very difficult for parents, parents started returning to their villages to dig.  The children could not walk and so they were left behind in the camps to suffer… – 40-year-old widow.  Her husband was abducted in the war and did not return.  She cares for her four older biological children and her young niece The origins and experience of poverty after war Poverty was noted to be oppressive to families and to bring suffering and misery to children. Participants talked of having lost most if not all of their personal wealth and resources (i.e. livestock, crops, structures) during war and displacement to looting, destruction and disintegration over time. This position of abject poverty was people’s starting point in re- building their lives and caring for their children. All of our cattle and the oxen for plowing were all raided during the war. We had to run bare-handed into the camps with our hands hanging loose by our sides, empty. And when coming back (to resettle in villages) we came back with our hands hanging loose with nothing and although we came back empty handed, without anything, we are struggling at least so that we can carefully nurture our young children to move on ahead; to ensure that they live a better life in the future. - 45- year-old traditional birth attendant, widowed and caring for 5 children  With human beings, if they are given birth to at least there should be some training and caring and providing what is necessary for them… There is no proper food; you are just trying to revive your home.  Other varieties of things needed for the compound like cattle, they are not there.  Goats are not there…all of these things have defeated the Acholi, they are not there, they are only trying to restore them and this thing is very hard. You have to dig (cultivate), you sometimes eat and at times  99 you don't. Somebody else may come and take your own things from the garden (steal) and this upsets us so much.  My words end there. – 34-year-old father of 6, with 2 spouses returning to the village after 19 years of displacement  Because agriculture was the primary productive skill base of the majority of people, they were highly vulnerable to weather disturbances and pests that impeded crop growth. In all three sites visited during the study year, droughts and rains caused crops to fail and all participants talked of a period of great and devastating hunger; several referred to this experience as another war. In the past granaries would be filled with food, livestock could be sold, or relatives with plenty could share, but current poverty meant they did not have the resources to see them through such times and their children suffered. We are in the period of hunger, there is great hunger.  The crops planted, sunshine has spoilt it.  No food has yet been harvested.  That is why we still don't have enough.  Life is difficult, the children are not getting enough…. Here children are sent to the hospital, they come back when their health has improved, but when they have been home for a few weeks, because of the bad food they are again taken back to the hospital... – Participant in FGD of elder woman conducted during drought  …you may be interested and willing to see your child grow well but poverty will oppress you. Right now, most people cannot afford to eat a meal in a day, they would wish to see their children grow well, but they lack anything to give their children because there is no food.  People’s food has dried up in their gardens because of the sunshine (drought). - Child Protection Committee Member FGD  Other factors reported to contribute to poverty in post-conflict was caregiver disability or injury sustained during war that impeded the ability to do physical work and provide for children; high fertility rates and large numbers of orphaned children that had to be cared for by extended family; and not having social support and/or land. The more of these factors experienced, the more difficult it became to generate sufficient income to meet children’s needs. Children’s basic needs go unmet In the environment of poverty, reports of children’s unmet needs were pervasive across all categories of participants during transition.  The situation was glaringly visible to the research team, who saw far too many children in camps listless and wasted.  The young children who were the subjects of caregiver interviews/ observation were weighed as an indicator of nutritional status.  Of the 12 children weighed during the drought (May-August) only one 2-month-old, breastfed infant was average weight. Nine of the children were  100 severely malnourished; at or below the first percentile for weight-for-age according to the World Health organization standards. Document review revealed a food and nutrition survey conducted in June- July 2009 in the Acholi region, including Amuru, that demonstrated a substantial decrease in food consumption between 2008 and 2009 and stunting levels above 34 %.  The authors related these findings to a number of factors including inadequate food production among those who had returned to their lands, and cessation of food distribution to the general population (UNFAO, 2009).  Caregivers made an effort to protect their youngest members during the hunger, with all participants reporting that when food was scarce, young children were prioritized.  Yet despite their efforts, often during this period food was simply not available. … it really gives me heartache.  I went to the hospital recently and many children were brought from Pabo; many were blood transfused, many were brought in with swollen bodies, I saw many being blood transfused……women are trying to take care of children but are failing because their strength and ability is almost gone. They cannot get enough to feed the children and if children are all the time malnourished, they will not grow well and if they don't grow well, in the future there is nothing much that will come out of them…  We all here have knowledge about feeding children, but what can knowledge do without food? NRC (Norwegian Refugee Council) taught us how to feed children and even many other NGOs taught us about nutrition and right now there are people who come from UWMFO (Uganda Women and Men's Financial Organization) and they are also teaching us about nutrition, they teach us about agriculture and how we can make children grow up healthy, they have a lot of knowledge they have given us, but what can that do without food?.…In the camp here as you move around, you will find children moving aimlessly, they pick up anything and eat it, even when it is dirty, they pick it up an eat it. When they find a little food thrown somewhere, they fight over it and you will find them crying.  Also, there are children here who are not strong against hunger, you will get them crying the whole day.  The mother comes back in the evening, cooks at night and the child will eat now while sleepy and that is why many children's bodies are just swelling, it is painful to see the suffering children here.- Traditional Birth Attendant FGD, Pabo camp  There were frequent reports of children being continuously ill with conditions such as malaria, diarrhea, skin rash and cough. For example, a child in one of the family case studies was ill 11 of the 15 times we visited her (see Appendix – Akot) and was admitted to hospital four of those times.  While not as severe, the same cycle of illness played out in the other five case studies. Furthermore, all reported times when poverty stopped them from being able to seek medical care, either they could not afford drugs, the cost of transport to the hospital, or the work time that would be lost if children were admitted.  Food was the frequently unattainable priority for impoverished caregivers and meeting other needs had to be prioritized by survival ranking.  101 … Most people still don't have money in their hands, that is why you find children without clothes on their body….most of the people in the community, their worry right now is to look for food…. other things don't matter. They will not mind whether a child has clothing or is sick….the majority cannot send their children to school, their priority is first food because you as a parent, food is always first for your family, food is the first necessity in a family, no one can do anything without food and most families only have the strength to look for food but not any other thing, they are interested (in promoting children’s development) but are just defeated because they don't have any means of survival.- FGD with the Child Protection Committee, while the group was held in a camp, most had returned to home villages Hard work, poverty reduction approaches and persistence People spoke of working long hard hours to rebuild, provide and bring their children home. This hard work contributed to familial betterment and when the drought passed, some participants recounted how their crops began to yield adequately if not abundantly. Children of families who had been settled for longer periods were observed to be healthier and had more appropriate weight-for-age. Those who did not have land and social support spoke of long grueling hours doing casual agricultural labour for cash or food, gathering wild vegetables from the bush, and/ or small scale trading for their children’s survival. Participants accounts suggest they valued a strong work ethic as the way to get proper food, meet basic needs and send children for education for a better future. Now that we have come back to the village, the people are really struggling [working with all their strength] to take care of the children.  So their life is really on cultivation, serious cultivation [of their land] and this struggle is aimed at helping so that the children can have the strength in their bodies.  So we are actually struggling now that we have come back to the village, on our own land.  We want to obtain enough food so that we can get money, then we get other things that can help us put clothes on their bodies and even send them to school to protect the children and this struggle is at a very high degree; it is not decreasing either. - 49-year-old traditional birth attendant, widowed and caring for 6 children  The data also revealed a range of additional techniques caregivers used to combat food insecurity and poverty: working communally in groups and rotating through each member’s land; exchanging food to gain greater variety; selling harvest to meet other needs; participating in group savings and loans schemes (a skill learned while living in camps).  All of these strategies rendered caregivers better able to feed and provide for their children.  5.2.3 Social (care-giving) environment of children in post conflict This section presents themes that illustrate the social environment in which young children lived during transition.  The major sub-themes are: 1) Survival based neglect of children, 2)  102 The vulnerability of children without parental care, 3) The social protection of villages. Survival-based neglect When caregivers had to work daily to meet basic survival needs, pre-ambulatory breastfed babies were generally taken along to the agricultural land where they would remain on the backs of their mothers or be placed in the shade, sometimes with an older child who was brought along to provide care.  However, many participants reported that once children were walking they could not be brought along and would be left in the camps. As one Amuru Government official noted “mothers are feeling conflicted because they have to go and work in the fields and if the child is a little bit older, they can’t take them.” But if it is in the camp, how can you check on them when you have gone to a garden that is so far away?  The garden can be far off, one belonging to a friend. Sometimes even five kilometers away, or even 6 km or 7 km.  You go all that distance and come back in the evening.  So that is the bad experience that women are facing in terms of raising children. – 29-year-old single mother raising 4 children between the age of 7months and 5 years  For families based in camps or resettling in villages close to camps, caregivers could commute to the casual labour site or village lands daily for work, returning in the evening. However families whose villages were far away could not move back and forth daily and left camps for extended periods of time, some reporting weeks or even months. This meant having no time to teach, interact with, or monitor their children.  While participants expressed the vulnerability of this situation many talked of having no alternatives. Early resettlement was lamented as being a very difficult time for children who were exposed to a myriad of factors hindering health, development and well-being. … because of this poverty the child cannot get enough food, nor enough clothes, nor enough teaching because the parent goes about looking for avenues to earn a living; there is now no time for guiding the child.- 28-year-old man, Local Council Leader in return village  Children when they are left behind in the camp, especially those 3 years and below, when you come back you will come and find they have been seriously beaten by other bigger children.  You may find when they have hurt the body of the child. You will come and find that no food has been given to that child and you will come and find trails of dried tears on the face and body of the child and you will find a lot of dirt has dried up on the body of the child.  There are some people who return and find when your child has ‘tale’ (dried up) and is dead from convulsions of malaria.  A lot of things are happening in the lives of children who are always left unsupervised. – 21- year-old mother of 1, living with her spouse in a return village after spending most of her life in camps  103 Participants’ revealed a hierarchy of preferred care options for young children who had to be left behind; a supervising adult such as a grandparent or neighbour as a first preference, followed by an older child in charge and lastly, children left amongst their peer groups. Sadly, reports suggested that many of the elders who would traditionally have provided supervision while parents were out cultivating had either died during war or were themselves forced to go out and work for survival. Additionally, many examples were observed of grandparents who had once again assumed the role of primary caregivers because parents had died, been abducted or left their children. … in the past we spent a lot of time with our grandchildren, but now, you cannot spend much time with them because you have to look for means of survival.  These days we the dayo (grandmothers), we go to the garden because we lost our sons who would have gone to do the work we are doing now and the gardens are far; you go in the morning, leaving when all you have done is sweep the compound and you just leave water for the child to use to wash his or her face. You go away and come back in the evening now to begin preparing food for them.  Your grandchild may spend lunch without food but in the past, we could feed them at least two to three times in a day.  We now do not have time to bathe our grandchildren.  We do not have time to tell them stories.  The time you are supposed to be telling them stories, you may be too tired to even talk. So, I see that our role has changed just because we are not spending much time with our grandchildren, we don't have time to teach them, we don't have time to cook food for them, we don't have time to play with them because we get involved in other work like casual labour, petty trade and digging in the garden. – FGD with elder women The vulnerability of children without parental care and provisions In Acholi culture, children had always assumed a care-giving and stimulation role for other children, so child-to-child caretaking during resettlement was not new. It was a time proven practice that served to meet many of the stimulation and care needs of children within the folds of the extended family.  However, what was acknowledged to make transition a uniquely vulnerable period was that children were frequently reported to be without adults in the vicinity to supervise and assist the child caretakers. In one remote camp, the team observed dozens of children of all ages without supervising adults. Additionally, people spoke of children being left without food or money to sustain themselves while parents were away working.  The following excerpt from FDG with siblings who remained in a camp illustrates some of the serious issues faced by children when parents were gone to the village for prolonged periods. Participant 2- There is always no one; they always go away all to the garden and you find very few adults within the camp and I may not be knowing them and cannot go to them for help even when something happens; even when a child is sick... Night hours are a nightmare to us.  104 Participant 3 -  We suffer at night. They (adult intruders) carry away our food and we hear them saying 'your mother is not around, your mother has gone to the village.’ Participant 1- They always see and notice that our parents have left for the village. Participant 4- They may even know you and your parents. Participant 2- At times we don't know the people who come to steal; we wake up in the morning not knowing who has taken our food, but at times we know the people. - FGD with 4 half-siblings between the ages of 9 and 13 living in camp with younger siblings while parents return to the village to work and re-build  A situation of even greater vulnerability occurred when young children were left amongst their peer groups (i.e. groups of children 5 years and below).  This would happen if older children were in school and therefore unavailable for care, or if there were no older children or supervising adults available in the family. This practice was observed in all camps and was noted by all categories of participants. An informal interview with an employee of UNICEF indicated that ‘children deprived of parental care’ was a major issue experienced during transition.  Child protection committee reports indicated that this issue composed 23% of reported cases in 2009. The following excerpt is from a FGD with child protection committee members: Participant 4-  Ah what I have seen happening here these days which is very bad in Pabo here, most people returning home, they leave children behind without food and you find the children moving aimlessly in the camp, they move near restaurants, you find them picking up discarded food and discarded millet bread, the ones which people have eaten and left. Participant 6-  Just yesterday I saw some two parents leaving their young children behind, children of 1 year and 2 years and even 3 years, they leave them home for the whole day, they go to their gardens for long hours, come back late in the evening and you will find the children hungry the whole day or not even breast fed… Participant 1-  There are those who do not have lapidi (child babysitter). You see, for us here once a child lacks a lapidi that child will always suffer the moment the parents leave for the garden.  Such a child will try to survive on his or her own and will not know how to differentiate that this thing is good or bad.  As the previous quote illustrates, when young children were left without adult supervision and provisions, participants reported a number of very serious outcomes.  The following outcomes appeared in the transcripts and are listed in order of frequency of mention: hunger (and subsequent malnutrition); falling seriously ill or being injured (falls, burns, bites, beatings) with nobody to help; suffering and distress experienced without comfort provided; missing out on teaching, guidance; picking up bad behaviours such as stealing, fighting;  105 wandering around or loitering aimlessly and unengaged; subject to predation by others in camp i.e. rape, theft.  Acholi caregivers placed great value in their children and as many of the quotes have demonstrated, there were high levels of knowledge regarding risks and outcomes if children’s’ needs were not met as well as the factors that would offer protection for their children’s futures. Yet the circumstances in post conflict transition rendered many unable to change their children’s environments and experiences. … with children if they miss all that we have been telling you of (their needs), in future nothing will come out of them.  There is nothing that they will do that will be progressive.  If we cannot help our children now, and we say that we shall help them maybe in two years from now, we shall be wasting our resources because they will not be much of a help to us….Our children will not be able to study, we shall not have a good generation. If we begin taking care of our children well now and we then take them to school, they will complete their education well, they will be able to support us and even support other great grandchildren.  But right now we have spoiled what would have been good for the future of our children.  Our children will grow up to be people who always commit crimes.  Our children, because they are not getting enough food and sicknesses disturb them a lot, in the future, we shall have children who all have mental problems. - Traditional birth attendant FGD participant, Pabo camp Social protection offered by the village When families resettled fully in their villages with their children they began to report lessening degrees of vulnerability.  In villages, even when parents were working in the gardens, they or another adult were generally within earshot and could hear children’s cries or children could go to the adults if needed. Homesteads were spaced far apart with only vast expanses of agricultural land and bush in-between so children would remain near the home where they generally had access to food, water, shade and wide open, controlled spaces for play. I have realized some changes at least in coming back home in the life of my children because the condition in which they were when in the camp was not good.  The camp used to be so oppressive they could hardly play well.  There was no particular playground or play space that they could find in the camp, they were not free. But now that they have come back to the village, they play anywhere and they are very free, they run over to the other tree, then come back to the other side and at least they have rested.  They are even quite free (the wind is blowing around them).  Even me, as a mother, I am feeling so free.  I don't have to keep on controlling my child so closely, protecting my child 'oh, I have to protect my child from so and so, or perhaps my child might do something bad in some place or to someone's property who is not around'. –Case study:  27-year-old married woman, caring for 7 children.  Recently transferred to the village from a nearby camp The data showed a positive trend in social-cultural support restoring across time when families resettled successfully in the village. After so long in camps where parents spoke of  106 having very little control for ensuring positive nurturing environments for their children, return was a most welcome restoration of the highly valued social cultural ways of the past.  This included restoration of practices such as the nightly wangoo, or family campfire, where family would come to unite, plan out how to meet needs, share songs, stories and teach children.  5.2.4 The regional resource and service environment of children in post-conflict This section will illustrate themes relating to the regional resource environment of post- conflict transition as it relates to young children.  The major sub-themes are: 1) Lack of services in return sites; and 2) Problems with targeting and implementation of services. Lack of services in return sites As was covered above, participant reports suggested that the majority of services provided to children during war and displacement by non-governmental and international organizations ceased to operate or were scaled down significantly when war ended and re- settlement began. …now, when people are returning to their original homes, there should be programs which should be targeting them when they are going back to their original sites, but at the moment they are not, there are no programs which are actually targeting people who are returning to their original sites, most especially when you talk about the children… - Government official, Amuru District  While participant observation revealed that there were a range of interventions operated by development partners and government during the post conflict period such as agricultural support/training programs, assistance with repatriation and/or food aid for “extremely vulnerable individuals” (people with disabilities, the elderly, persons who are HIV positive), hospital-based nutritional supplementation for children who attended with serious under- nutrition (when supplements were available), and building of infrastructure such as health centers and schools, many of these services were insufficient in scale or too centralized in location to meet the needs of the dispersing population. Furthermore, while many programs benefited children indirectly through bolstering the family unit, few programs targeted young children directly. For instance, in Pabo camp some participants recalled approximately 5 centers that had existed during war, however all but two had been abandoned and fallen into disrepair during the post-conflict transition- a time when they would have been highly beneficial.  The two that were confirmed to be in existence either charged high fees that were unattainable to most or targeted specific populations such as children with disability.  107  As one employee of an international NGO reported, there was a significant funding gap post- conflict - the conflict-oriented funding had been withdrawn and development funding was insufficient to replace it.  This was a point of resentment and frustration clearly for leaders and development workers, but even more so for many caregiver participants. Upon return to villages (particularly remote villages), they lost or had substantively reduced access to services and infrastructure for their children. These were services that had come to be highly valued during camp living like health care, clean water, and education on child health. Some villages reported a lack of markets that made it difficult to access needed staples like soap, salt, sugar and sell foods that they had grown in order to get resources to support children. … the lack of school and then also missing a big therapeutic/ supplementary feeding centre to encourage the brain and thinking of our children.  So ignorance is going to be the result in the lives of our children….Because there is no hospital, most of our children will now not live.  The result will now be many graves filling up the whole place. People say that there is change with the dawning of the day, but it looks like with us, the dawning of the day only brings us problems every day. – 30-year-old Rwot Kweri (traditional chief) returned to village  …what is causing life to be difficult now that people are returning and the war is ended is that where people are returning to there is no proper water, no hospital, no schools….that means it is not easy to keep good health among the people. – 25- year-old father of three, husband to two women, living in small transition camp, ancestral land is far away and is under dispute Problems with targeting and implementation of services Some noted that child- focused services being offered were a poor match for the most pressing needs.  Examples included, nutritional education being provided during drought when children did not have food to eat, and health centers that open only during daytime hours 5 days per week.  Some services designed to reach children at the village level such as the Village Health Teams (VHT) who were to monitor, provide health education and dispense basic drugs such as malaria treatment, were spoken of as having started out strong, but then faltered in effectiveness due to a lack of resources such as drugs and support, compensation of workers and monitoring. …it (VHT) has reduced the strength and level of sicknesses that disturb children-  it had actually gone down - but beginning from the end of the past year when the medicines were finished, that is when sicknesses began to disturb children again so much.  Also in this place the death rate has been going higher. - 25-year-old man, Village Health Team member and Rwot Kweri (traditional chief).  108 This pattern of faltering services was reported repeatedly by community leaders, both government and frontline workers. They spoke of the deficiency of monitoring, lack of sustained support and limitations to the evaluation of implemented programs.  While organizations were strong on initiating, participants felt follow-through was often poor and they were neglected in communities as the program that had offered so much promise for their children petered out. This lead to expressions of both disappointment and a consequent lack of trust in the promises made for their children. … when these (early childhood care) centers are started by these development partners, people have very high expectations. So people started sending their children to these centers because the caregivers have been promised they will pay just a certain amount of shillings. But now when conflict ended people (implementers) began just to desert the centers … and that is why you see them dying out because the NGO started them and when their contract expires, we have no support for that centre. – Amuru District Official Some participants recounted maintaining their homes in the camps for longer periods or leaving their children behind because of proximity to services such as schools and health centers which were not available in return sites.  The one program consistently reported to reach children, even those in distant rural locales, were immunization services. Immunizations were provided through the cooperation of government agencies, international organizations such as UNICEF and NGOs on an outreach basis.  Community leaders would gather their people to gather on the expected dates to receive services and reports suggested high levels of satisfaction.      109 Chapter 6:  Adaptation and protective factors in a war zone  6.1 Synopsis From fetal development onwards, humans are biologically programmed to adapt to their environmental conditions. The previous three chapters have detailed the adverse environments experienced by young children in northern Uganda due to conflict and displacement creating omnipresent risk. However, many of the young children observed showed aspects of healthy functioning in their environments despite its challenges.  Further, there were numerous examples of families and communities striving to promote children’s well-being. This research aimed to explore not only the environmental factors that put young children at risk, but also the factors that offered protection from risk (protective factors) and promoted positive adaptation. This chapter interweaves findings across the entire study with the narratives and observations from one of the case studies to illustrate examples of children’s adaptation and protective factors present at the level of child, family and community. These positive or protective factors were far less abundant in the data set when compared to accounts of risk, thus reflecting the horrific experience of war, however, the examples are present and deserve to be highlighted. The findings are again framed in broad themes:  1) children as active agents of their own adaptation; 2) protective factors provided by family, and; 3) protective factors provided by community. The findings presented under each broad theme are further delineated by sub themes.  6.2 Findings The chapter begins with an introduction to a child we call Okello (names have been changed to protect the identity of the participants):   110 Field journal notes 1:  The day we met Okello July 6, 2009 As we walk through the camp we see two women sitting on the ground in front of a mud hut selling cowpeas.  One has a young child on her lap- he is visibly undernourished and his eyes are yellowed.  His name is Okello.  We ask if she would be willing to talk to us about early childhood and she agrees.  He crawls after her as she prepares a small room for us to talk. The family has two rooms in a rectangular shaped house in the camp- walls and floor are packed mud, roof is corrugated iron - it is very small.  They have grass mats on the floor, one bench for visitors, one stool, a radio, but few possessions otherwise. She (Mom) tells us they have lived in this camp for 20 years, but when we clarify the year they came, she says 1996- so 14 years.  She tells us they are still living in the camp now because her husband has a physical impairment.  He is missing a lower limb as a result of a landmine and the other leg is also weakened.  This limits the efficiency of his walking so it is difficult for them to go back and re-build in the village.  We ask her how many children she cares for. There is one 15-year-old boy, but he is not her biological child.  As for the ones she gave birth to, she tells us she has a 12-year-old girl, then a 10 year old, 8 year old, 6year old girl (Okello’s lapidi), a 3-year-old boy and Okello who is the youngest at 1 year, 25 days old (7 children total).  She had one other child who passed away and is buried here in the camp near where they live now.  The child died in 2003 at the age of 1 year due to a severe systemic fungal infection, and diarrhea with puss. There was no good health centre back then … Mom is 27 years old, and has never been to school but is clearly a very intelligent and resourceful woman…. She tells us she does not have a regular source of income, but she “sits by the wayside” (sitting by the footpath selling small items- as we found her today). She buys charcoal and/or beans and then re-sells them for small profit.  She also makes mandazee (donut-like items)- she taught herself how to make these after sitting and watching another woman do it in the market. Additionally, they have a small plot of borrowed land near the camp that they cultivate… Okello thrusts his arms towards his mom until she takes him and holds her flattened breast out to feed him.  She doesn’t have much milk as she too is under nourished. His eyes are sunken and his belly enlarged, today he weighs only 6.5 kg (less than the 3rd percentile). According to Acholi caregivers most children here begin walking before their first year (around 9 months).  Okello is not yet walking, but then he is malnourished and ill, and as mom notes, this affects children’s activity level and rates of skill development.  111  6.3 Children as active agents of their own adaptation This section will explore the theme of children as active participants in their own development, which is particularly evident in circumstances of war and displacement that often require children to fend for themselves. The theme will be divided into the two sub themes of active learning and play, which are evident in the following excerpt from the field diary about Okello.  Field journal notes 2: Excerpts about play and active learning July 6, 2009:  (Mom) says that when she plays with Okello, it is often he who initiates: “most of the time children are the ones who initiate play with an adult.  A child will run to you when he or she is happy and holds your clothes and so when a child does this we also play back.  At times a child may come to you while dancing, so when you see that, you also dance or imitate the dance. So that is how adults play with children.”  She talks of how playing with a child who has initiated play shows love.  In the evenings when they are sitting together she talks of how the children request and are obliged with songs, riddles, folk stories and dances.  She notes that children imitate everything - at first they sing and dance with older people and then later they do it themselves when the adult is not around.  July 22, 2009: We find Okello happy and in good spirits today.  His older brother turns up the radio and Okello dances bouncing his knees and moving his head as we laugh. He is standing independently now, although briefly, and is able to move from standing to squatting and back up.  We ask about how Okello plays and mom tells us of how he likes to kick balls, or any other thing, and to dance, as we see now.  “He plays by himself by picking up a stick and he hits anything he finds around. Or at times when you get things like a tin (empty container), he hits it with a stick and when it begins making a nice sound for him, then he begins dancing to the tune by himself” “… with his friends the moment he notices they have gathered somewhere and they are doing something, he moves there and strains his neck to see what is taking place… he will follow where there is noise and he will go where they have gathered.”  Mom tells us that when a child plays you know that the child is healthy because play makes children happy.   Healthy children will be off with their friends, not clinging to their mothers and will sometimes play until they fall asleep.  112 Active learning In this passage, Okello’s mother described how her children imitated adults, they sought out play opportunities, and they practiced skills. This reflected the Acholi people’s recognition that children are active learners.  While Acholi caregivers acted as teachers and guides, it was assumed that children learned and developed skills independently as they listened, watched absorbed, imitated, repeated and eventually mastered what they saw adults doing. …he may be silent, but the child will be hearing and noticing the way you talk with him.  You also place him in the midst of people and he listens.  Even when you place him in the midst of young children he listens.  He also learns when he is in the midst of fellow children. – 20-year-old mother lives with her spouse and cares for her two biological children plus 4 children of her sister-in-law. Settling back in their village after 12 years in a displacement camp  As active learners, young children not only absorbed and learned from the experiences they were immersed in, but sought out opportunities to engage with others and practice what they learned. This included participating in the daily life of the family unit, by trying to do household chores, or even following their mothers to work (which sometimes led them to get lost in the camps). When possible, adults and older children fostered their drive to engage by including them in activities.  It was felt that imitating adult behaviours and responding well to guidance or instructions were signs that a child’s brain was developing properly, which meant that the child ultimately would grow into a positive, skilled adult. If it is a girl of two years, the moment she observes you cleaning the pot for sauce, she also begins to wash the pot for cooking sauce. She begins to scrub utensils any which way. The ones that are not cleaned properly, you must repeat it after her [wash them again] so that they are clean.  But if it is a boy child, in most cases, the kind of work that he always learns is in picking up a hoe, then picks up the compound broom and observes how his fellow children do such things. - 59-year-old married grandmother, caring for three of her late daughters children, Amuru Sub County  Personally this is how I see it; if you are doing some work, a child may imitate you so you must not chase away that kid.  Let him learn.  An example can be cooking; when you are cooking, a child can also come and mix food, however, you should not harass him, but let him be careful with the fire and hot food.  Let him be near you so that he can learn like that. – 47-year-old father and member of the village health team, Amuru sub county  The moment they see us doing it, they also come and begin doing it.  For instance if I begin sweeping the floor, he will watch and later also pick up the broom and begin to imitate.  So as he grows, he will learn to do it better.  – 13-year-old female caring for 3 younger siblings in Pabo camp  113 The belief that children developed knowledge and skills independently was particularly evident when participants spoke of orphans or neglected children.  Although orphans frequently did not receive the same amount of direct teaching as other children, they were still expected to fulfill their roles as learners.  This was illustrated by proverbs that recounted how neglected children would and should learn vicariously through eavesdropping at daily communal sites such as the evening campfire or places of work: …you will hear the Acholi saying that an orphan child develops depending on the teachings received beside the granary [a structure for storing food].  The child has to learn from the side of a granary when a child is not taken care of well, he is not loved, so he goes and sits by the granary as he listens also to the teachings/trainings from there…- 30 year old Rwot Kweri living in a village in Amuru Sub County Play Okello’s story highlighted young children’s drive to play as a form of active engagement and learning. Play was valued in Acholi society.  It was seen as being the natural tendency of a happy, fit child and all categories of participants considered it to be a key indicator of health and contentment. Furthermore, play was described as a determinant of health, and important for the development of competence and well-being.  A child who played would become strong and healthy in body, while acquiring skills and establishing social relations. Further, when children were played with, it demonstrated that they were loved and gave them positive feelings such as joy, happiness, freedom and ease in their lives. As such, play was clearly expressed as a protective factor for children in war. Participant 2- You must play with the child if you love the child.  You must play with him to make him understand his surroundings and to know things... If a child plays it indicates to you that such a child is bright because it is through play that a child learns.  Consider those children that do not play, in most cases when they grow up they do not turn out to be bright.  Besides when a child does not play, he can never be healthy.  Also if you insist on a child not playing, 'don't play such and such a game', the child will just sit quietly, withdrawn without speaking.  He just looks on staring.  For a child to be healthy, you must allow him time to play. Participant 4-  Say the fellow children are busy playing, but that child is not doing it, you the mother prevents him, so the child does not learn anything in the form of playing. Such a child will not get used to his fellow children; he will be afraid somehow. - FGD with primary female caregivers in Amuru Sub County  Personally what I know is that in the life of a young child, play is there to bring good life and good feelings.  When I observe her playing, then I know that this child is healthy.  When she is playing in the compound, she can run to the extent that you can tell that this child is actually playing with good health. … When a child is playing,  114 that is when you can see that this child has a healthy body because, if you observe that a child does not play, he just sits still by your side when you are an adult, you will then know that this child does not have good health.  You must ask 'what is the matter with his life?' – 32 year old single mother of 6 living in a camp in Anaka sub county, estranged from her abusive husband  …. The benefits to play I would say a child may begin playing with a ball for instance when he or she is young and the child will reach school and will do it much better. The results of play are always seen in a child in the future. –Widowed mother of 5 living in a camp in Pabo Sub County  Being in camps certainly did not stop children from playing.  Participant observation and photo documentation showed young children involved in a wide range of play activities and playing with a variety of objects. As illustrated in figure 4, the poverty of the setting didn’t restrict the availability of toys because they could be created from discarded items. For instance, infants shook and patted plastic bags to make a pleasing sound.  Plastic bags were also tied together to make balls.  Sticks became drumsticks and old leaking jerry cans and suitcases were used as wagons for pulling young children.  Emptied containers were filled with sand or pebbles to make rattles.  Objects lying around and even the sand on the ground satisfied their curiosity and drive to manipulate, taste, hear, smell, and see.  Figure 4: The toys of young children  115 Field journal notes 3: Okello’s mom talks about how children play in their first three years July 22, 2009: (Okello’s Mom) “ In the first year of a child, a child begins playing in the sand, they like gathering heaps of sand, gathering anything they find around and they play with it. You may call a child at that age when he or she is playing in the sand; he or she will not listen because he or she may be so excited with the sand. Ok, then in the second year of a child, if the child is a boy he will always imitate digging or imitate kicking things like a ball or imitate building a house like adults are building.  But if the child is a girl, she will imitate cooking food - picking tins (empty containers, lids, bottle caps) and pretending to cook in it, that is what children do in their second year.  In the third year of a child most children tend to know what they do. They know that when they do this, the result will be this. So a child will want to do the real thing and not imitate. Like for example they used to imitate cooking, a child will want to now really cook, like he used to gather sand, he will no longer gather sand, he will want a real toy to play with. So he may pick a tin and begin making real fire to cook real food in it. They may pick three small stones for the fireplace, make fire with small sticks, pick beans and water and put in the tin, and begin cooking.  The child will do exactly what the mother has been doing.  Or when it is a boy, he will go and pick the real hoe and begin digging with it outside or he will pick a pen and say lets go to school or he may even pick a pen and begin teaching the friends where they have gathered to play, so that is how they behave in their third year of life.”  As described by Okello’s mom and depicted in Figure 5 below, older toddlers engaged in pretend play.  Pretending to cook was a favourite game in which ‘tins’ (empty containers and lids) were used as pots (picture 2), and both male and female children were frequently observed acting out childcare scenarios such carrying their “babies” on their backs. Additionally, they would build houses, roads and other structures out of mud. For children who had returned to the villages in post-conflict, there was a great playground of naturally available objects, such as passion fruit shells that could be used as scoops for digging. …then they can pretend to be weeding ‘oh, let me weed’ yes, so they uproot grass at the edge of the compound saying that they are mothers. Then they say ‘you children stay there’ and then they continue that ‘eh, chase away that hen! Let it not spoil things in the house’ ‘you stay right there, right there’ -72-year-old widowed grandmother caring for 4 grandchildren after the death of her daughter from HIV, village Anaka sub county   116 Figure 5: The pretend play of Acholi children.   6.3.2 The role of family in promoting young children’s positive adaptation and resilience Organizations that are focused on helping children in war zones frequently strive to keep children and families together and to reunify separated families. The support and nurturance of family can mitigate the risks a child faces due to war and displacement.  The previous chapters illustrated how families’ ability to meet their children’s needs in a holistic manner was thwarted.  However, there were also numerous examples of how families strove to protect their young children despite the immense challenges of war and the camp environment. This section begins with excerpts from Okello’s case study that depict the various roles his family played to support and nurture him. The four sub themes that emerged from the excerpts are: 1) labouring to meet basic needs; 2) love, attention, and responsive care; 3) goals and hope for the future; and 4) child-to-child care giving.  Field journal notes 4: Excerpts highlighting the role of family in Okello’s life July 6, 2009- Mom tells us the lapidi (his 6 year old sister) spends the most time with Okello- because she (mom), like many of the adults, has to put most of her attention on the gardens and work.  They (parents) are gone much of the day and the children are left amongst their fellows. This is unlike the past when family were close by and would spend hours with their children.  She talks of how the lapidi makes him porridge, bathes him, helps him to dress, removes clothes to pee or poo and talks to him and plays with him. We ask her about the role of mothers and she tells us of how they hold most of the care responsibilities such as feeding and bathing- but they also must spend a lot of time getting and preparing food, maintaining the home, taking children to health centre when  117 they are ill and teaching discipline (good and bad, what is dangerous).  She talks of having to stop Okello from fighting, biting- she talks to him but says she does not beat him. July 15, 2009- When we arrive Okello is standing leaning against a strong young man who is sitting on a bench (dad).  Okello is gnawing on a piece of sugar cane.  Mom has gone to the market; dad says she was down with malaria all day yesterday but is feeling a better today.  Dad moves the bench inside and we sit with them.  He has his prosthetic limb on and tells us of how he lost the leg in 1996 when he was walking from the village to the trading centre and stepped on a land mine.  He was 14 years old at the time and not yet married.  We comment that it is really nice to see a father caring for his children and he responds that he loves the children.  He had been away the first couple of times we came, but usually he is around and he loves the kids -they were clearly very attached to him too. Okello begins to cry after a push from his brother makes him fall- dad calls him over. Okello sits up, crawls over and as dad pulls him to his lap he promptly falls asleep. Okello is looking healthier and happier today and it seems he has gained .4kg (weighs 6.9 kg today)… Dad tells us of how he goes out to cultivate, but has had to hire a plot of land closer to the camp because his ancestral land is too far for him to walk to now.  They want to return to the village and he has tried twice now to bake bricks to build them a hut only to have them ruined by the rains.  He is planning to try again in September.  August 28, 2009: We find Okello sitting around a pot eating with 5 other children.  It is porridge of maize and soy- a mix provided by WFP (World Food Programme).  Mom bought it for the children from a HIV+ person who is still receiving food aid as an “extremely vulnerable individual”.  It is not uncommon for people to sell off food rations that have been distributed to them in order to procure other items.   Mom has been going to the garden a lot lately.  Their harvest this time is looking good but they are trying to keep the birds away so she takes turns with her husband staying with the crops.  If they try to put a scarecrow up people just steal the materials.  Okello is now walking on his own- he started about a month ago and is saying words like “give” and “come”. When mom takes his porridge away he stands and with a bow-legged gait takes steps towards her crying and reaching for the food –so she gives it back.  118 Today he weighs 7.1 kg. The lapidi grabs Okello and cuddles him and makes baby noises and they both laugh. He seems a happy child - he is clearly loved and attended to by his family despite their very limited resources.  October 16, 2009 (Stella’s notes): Found Okello and the lapidi playing with a ball, mom cooking in the kitchen and dad building a bathing shelter.  The whole area in front of their home has beans and rice spread out on a tarp and there is no space for passing. Mom sees me as I greet Okello and rushes to get me a bench to sit on in their sleeping room.  I sit inside and notice 4 sacs full of beans.  I ask mom how they have been and she tells me they have been busy with garden work and she shows me their harvest and beans spread outside and rice.  I could not believe my eyes because only two hands to harvest that much is really great and with the husband having a disability too- they left me dumbfounded- they are really a hard- working couple.   A child of Okello’s age is highly dependent on the care of others.  The above excerpts demonstrate how his family’s combined efforts served to protect and nurture him.  This is not to say that all aspects of his development were positive.  Okello was clearly malnourished and frequently sick.  He also sustained injuries, witnessed violence and fighting, and at times went hungry while his parents worked to ensure the family’s collective survival.  However, the family’s ongoing devotion to protecting Okello as best they could was obvious to the observer. Labouring to meet basic needs Okello’s caregivers worked extremely hard to provide for their children.  With the insufficient external support provided during active war, and the total dearth of support such as food aid or repatriation assistance after war, intense and prolonged labour was required to obtain necessities such as food, shelter and water.  Okello’s mother suffered chronically poor health because of this labour but persisted for the sake of her family:  You see in those days in the village (in the past) you would not carry firewood for survival or carry charcoal for survival.  But these days because of the war, you are supposed to carry firewood that is very heavy in order to sell it so that you get money.  This has brought me problems and weaknesses on my head; my head always pains...At times I may sit, someone may talk to me and I forget what he or she has said…also even my chest always pains because of the heavy loads I have been carrying on my head.  Another example (of the loads carried) is the things I  119 used to grow in those far gardens. I needed something to carry them with (i.e. a bicycle) but because I did not have money I would carry the harvest from the garden myself.  As the theme of familial labour was explored in Chapter 5, it will not be repeated here.  It is salient to note that it was the hard work of parents that made it possible to meet at least some of the needs of young children who were highly vulnerable in times of war and in its aftermath.  Further, hard work was often reported as the sole means of overcoming abject poverty at the familial level, and thus through their labour caregivers sought to protect children from poverty. The majority of participants expressed that poverty was a barrier to good outcomes for children, and conversely, that possessing resources was a factor that contributed to better outcomes. Those who had more wealth could invest in their children’s health, education, and provide better food, clothes, and shelter.  Investment could make a difference in the long term, as healthy, educated children would have more opportunities in life. As is illustrated in the following quote, participants knew that the poor did not get the same chances to move forward in life, they struggled day to day to put food in their children’s mouths. Who would you say are good caregivers and why? Ha! In the camp here, with this poverty in the camp? There is no one taking good care of children here.  All children when you move around, you will see their bodies swollen; there are no healthy children around here. Maybe those with "cinge odyak" (means wet hands-a word for someone who is wealthy), those are the ones, I may say are successful caregivers, they are taking their children to good schools, their children eat good food. I have seen them around here…  They do not lack anything... The children are very healthy, the bodies of their children look completely different from our children and the children behave well, they don't insult people. – Widowed mother of 5 (approximately 40 years old), living in a camp in Pabo sub county and struggling alone to support her children with food, none are in school and all are malnourished Love, attention and responsive care Researchers observed that Okello’s parents reported that they offered him lessons, care, comfort and love - when they were around. This was true of most of the primary female caregivers involved in this study.  Children for the most part were highly valued and their families wanted to do what was in their power to nurture and protect them from the horrors they themselves had lived through.  120 I would like her not to suffer the way I suffer.  I want her to live well. What will you do to make her not suffer? I will not tell her what I went through, I would like her to grow up a happy child.  She should not know the problems I went through and the way I feel.  I would like her to not suffer like me; I want her to grow in peace. How will you let her grow in peace? I will take care of her and not permit any harm upon her.  I will not reject her or chase her like my mother does to me.  I will not be beating her. - 16-year-old single mother living in a camp  When we were conducting primary female caregiver interviews, it afforded caregivers the opportunity to sit for a while.  Their young children almost always flocked to them during this rare stationary moment, providing researchers with an opportunity to observe their child- caregiver interactions. The young children in this study demonstrated behaviours indicating strong attachment to their caregivers – following their caregiver, crawling over the caregiver’s body, showing contentment and ease in her presence. The children were physically welcomed by their caregivers, who sat the children on their laps, breastfed the children, or tied/laid the children on their backs as they talked with us.  The children frequently fell asleep when this comfort was provided, even children who were highly and visibly distressed due to hunger or illness.  The theme of love, attention, friendliness, and/or closeness was spontaneously raised as a need of young children in just under half of all transcripts.  Participants indicated that it was a protective factor for children and important for development: So, you breast feed the child when you are also happy while he is still on the breast. You must also look into the child’s eyes as a mother, you soothe the child, you keep on soothing and soothing and soothing, then you find that the child is happy until the child is able to walk.  Then you can trust that that child is ok….- 72-year-old widow caring for four of her grandchildren in the village.  If the child does not grow in good health, even if certain things are missing, there should be some love from the parents, besides food.  So this child, if there is no love, the child will not be clever even in class… I think for a child to grow well, he must experience the parent’s love – 25-year-old husband of 2, father of 3, working as a Child Protection Committee Member, village, Amuru. Researchers general observations of the participants revealed that when the children cried, and family members were around, caregivers immediately tried to determine the cause and sooth them. When the children got into trouble (i.e. picking up a dangerous insect or getting  121 into a scuffle with their peers), they elicited the attention of whoever was around, and the children were admonished and corrected.  Caregivers offered attentive and responsive care when they were available to do so and many spoke to the importance of remaining close to young children as another means of protection. If this one is to grow well without anything to prevent it, she should live closely with me.  I should not leave her anywhere but because of searching food sometimes I leave her alone. Why do you think you should live closely with her …? I think this because this child started life living alone, by herself while an infant and her mother left her -- so I should make up for the love she missed….- 40 year old aunty caring for her young niece in a displacement camp.  This home, we have elders living in it such that when a child has no mother then this elder must soothe him when the child is crying since the mother will have gone to the garden.  So he becomes a mother of that child at that point, the very person who is at home, who has not gone to the garden should be the one to soothe the child and comfort him asking ‘why are you crying?  Please keep quiet, your mother will come soon’- 81-year-old grandfather, husband of two, caring for 5 children in a village. Goals and hope for the future Field journal notes 5: Mom relays her goals for Okello’s future Post-script May 2010:  My admiration for this family grew with every visit.  Their extraordinary strength, knowledge, values and openness was incredibly inspiring.  When Okello grows up, mom wants him to be healthy, to study so he knows what is in the world. She wants him to learn to cultivate and take care of home like they did in the past, such as building granaries and pit latrines.   She wants him to get a job like a government worker.  She wishes to see him become a person of integrity; disciplined, trustworthy and good to others.  She sees herself as the agent to make that happen through how she talks to Okello and her other children, instructs and cares for them, how she shows them love and tells them the truth. Given the type of family Okello has, we cannot help but feel that despite the immense barriers, he has a fighting chance of becoming all she dreams of.  Like Okello’s mom, all of the participants in this study had dreams for their children’s future – even if they were feeling quite defeated. They wanted to bring their children home to their villages and raise them in an environment of peace where traditional protections could be restored. They also wanted them to become good people who related well with others and  122 to develop skills that would help them do well in life.  All categories of participants identified similar skills as important.  These skills were divided into four primary areas (listed in order of frequency of mention):  1) formal education, 2) cultivation and household maintenance, 3) professional work, and 4) trades and other handiwork skills.  Further, participants acknowledged the generational impacts of a child acquiring the skills needed to succeed in adulthood. As one Traditional Birth Attendant stated: “If at least one person in a family studies, that person will be able to help, if no one studies, poverty is the result”. Families were highly motivated to work hard and teach their children because it would ensure a better future for the collective as well as the child. Participant 2-  Labela [name of a legendary Acholi man] actually they say that he was a rich man. Participant 4-  But the kind of wealth that he possessed was that of livestock only - he had no children.  And that is why the Acholi say he is just rich with livestock for nothing because he has no children. Participant 5- It is as though he has no future…he was that kind of person who could despise his fellows assuming that he was self reliant but he lacked wisdom so the Acholi people say 'if that is what it means to be wealthy, that kind of wealth of Labela and his like, it is totally useless this financial wealth’. Participant 1- because he had no one.  He had no child completely. - Focus group discussion with elder men in Anaka Sub County  You should pay for a child in school, feed the child, buy clothes for the child.  All of your struggles in life are for your children. If you as a parent are paying for your children in school, you can never wear good clothing, as long as you have one you can keep clean, even when people laugh at you, you will not mind because you know that when your children study, you will reap your rewards in the future.  All the money you get, invest it in the children- make the child happy…because of the good example I have shown my child, my child will also do the same to his children and this should happen from generation to generation.  That is also a way of taking good care of your family.  You should instill it in your child’s mind that it is good for your child to invest for his or her children. - FGD with elder women in a camp in Pabo Sub County Child-to-child caretaking When caregivers were stretched too thin during and after war, child-to-child care giving became a major source of support for young children, and was felt to be an additional protective factor. Very young breastfeeding infants spent the most time in direct contact with their mothers but as the infant grew and became mobile, the child spent more time with the lapidi (babysitter), other siblings, neighbour children and the peer group. These fellow children provided much of the daily care of young children.  123 With the role of a babysitter for a child of three years and below, the babysitter even does more work than the actual mother of the child.  You see a young child needs a lot of protection because a child can run over and cross the road, but you find when the babysitter is protecting the child, even from the road when you are not there. Then when the child is hungry, when you are not around, the babysitter gives him food.  Then at times at around this time, the babysitter will have bathed the child twice. Then you can leave some flour and when you come back the babysitter will have prepared porridge for the young child and given it to him.  Then also when the baby poos in your absence, you come back and find that he or she has washed it and that is why I say that the babysitter works more than the actual mother of the child because during daytime whatever happens to the child, it happens in the presence of the babysitter.  And when you come back, that is the only time when you relieve the babysitter of her duty and yet, the babysitter will have done much of the work.  – 59-year-old married grandmother currently caring for three of her deceased daughters children As illustrated in this quote, the child caretaker assumed responsibility for monitoring the charge and mitigating risks. He loves to go towards the evening fire, so then I carry him and take him into the house and I tie him on my back and then he goes to sleep. But why do you tie him on your back? Because he will have gone towards the evening fire and yet I don’t want him to get burnt. - 6-year-old female in Sibling FGD recently returned to the village. The lapidi and other children with whom the 0 to 3 year olds spent most of their time were their primary source of developmental stimulation. The young ones were included in the play of older children. Sometimes they were assigned a role in the play; sometimes they pushed themselves forth into the action hindering the activity as they played haphazardly not yet possessing the skills or aware of the rules of the game; and sometimes they joined the action tied to the backs of their lapidi. This afforded young children the chance to see, participate and attempt to emulate those with more advanced skills.  When lapidi wanted to play with their friends without the charges, they generally reported that their charges were placed on the sidelines close to the action, or left within ear shot or close enough that they could be checked on. … when a child can walk then they begin to play amongst other young children. Even at 6 months of age, another child can carry them and they go to play amongst fellow children. That is when they begin to play….That is, he first watches how his friends do things, then he also begins to do them. - 30-year-old woman living with her spouse and 5 children (4 biological, 1 brother in law) in return village in Anaka Sub County.  How did he learn how to sit, crawl, and walk? He learnt this from other children who come to play here. Like walking and standing,  124 they would hold his hands and tell him to stand and that was how he started standing and then later walking. – 20-year-old mother of 2 recently returned to the village Sibling caregivers had a different view of child development than Acholi adults, who sometimes described it as an unfolding guided by God’s will.  In contrast, sibling caregivers in FDGs consistently stated that they acted to help children develop. Sibling caregivers talked about the numerous ways that they encouraged the child to gain new skills, such as making or providing the ‘toys’ shown in the previous section.  Descriptions of how physical development was encouraged were particularly detailed and included techniques such as luring and enticing children to move by calling them; reaching out to them; clapping and praising them; talking baby talk to them; providing them with something to reach for; or using an aid or toy to support them (such as a basin to support them in sitting or the stem of a cassava plant to stabilize them in early attempts at walking). I pick a tin (empty containers used as toys) and I try to give to him so that he may take steps, as he moves the fingers in order to hold. I keep moving on and then he moves his feet, that way, he learns to walk, just like that. - 7-year-old girl living in a village in Amuru Sub County cares for her younger sibling Sibling caregivers encouraged language development in children by telling them stories and riddles as well as talking and singing to them. They encouraged cognitive development in numerous ways through their play and interactions, and even taught about formal education when they played ‘school’.  This activity involved teaching what they had learned in class, such as reading, writing, and math.  They looked at pictures from their schoolbooks.  They drew in the sand and their siblings tried to copy them. Given that many of the adults, and particularly primary female caregivers were illiterate, children who had been afforded the opportunity for education were a valued resource for encouraging and modeling for young children. He will also begin to teach his sibling, he will begin to ask him ‘what is this?’ Especially when they are playing with their friends, they ask ‘what is this?’ He will keep on teaching his brother like that, and the next day the brother also continues in that manner.  That is how it has been with all of my children that I have been giving birth to.  I begin to observe how they learn, just like that.  –68-year-old married grandmother caring for 4 grandchildren in Amuru Sub County  In the following excerpt two girls aged 7 and 9 talked about how they teach their siblings in a FGD: Facilitator- How do they perfect their talking and their games? Participant 3- With games we are the ones who keep on playing with them and we teach them. Participant 2- They stay (with us) and they keep on learning better because we keep on playing with them and most of the time, they keep on  125 insisting on begin carried by us. Facilitator- Do you ever spend time naming, counting or drawing things? Participant 3- For me, I count for our young child, numbers one to ten. Facilitator- What of you? Participant 2- For me, I count two reaching to three. Facilitator- And what do you do? Participant 3- For me I draw pictures for our young child in the soil and then he tries to imitate it in a rugged way.  When asked to describe what a young child learns in the first, second and third years of life, sibling caregivers accurately identified the time frames in which different skills emerge. They reported that in their first year children recognize people, cry, lie down, suckle/eat, sit, crawl, stand, vocalize/talk, and play.  In year two, children’s speaking and eating/chewing abilities improved and they began to play with their peers as well as collect play materials.  In the third year of life, young children began to attempt to get involved in family life by learning, imitating and trying to perform household chores such as fetching water or sweeping.  They played better with others, talked more clearly, started singing and exhibited a strong will in becoming stubborn.   Many of the sibling caregivers were able to describe how one stage of development led to the next as the child learnt through observation, imitation, and the repetition of activities. … children learn to stand but do not stand well, they stand and fall and then they learn to begin walking, they walk and fall, they keep on falling until they learn to walk well – 9-year-old boy who cares for his 2 year old brother, living in camp in Amuru District  Field journal notes 6: Excerpts about Okello’s development and the role of lapidi December 3, 2009: Okello is learning to talk and now strings two words together: “mama come”, “mama give”, “ mama go” in addition to expanding the vocabulary “pii” (water), “dek” (food). He is imitating words now and even says “ mono, allo” (Foreigner, hello! – an attempt at English).  He will follow directions like going to get a cup of drinking water or a plate and will come when called.  His older sister gets him to say numbers and will draw in the sand for him.  He still likes to play with a ball although he falls when kicking sometimes.  He also enjoys playing with “cars” (i.e. the older children cut up containers or used cooking oil tins and add wheels made of bottle caps or rubber from flip flops) and he pulls them along the ground with a string.  126  Participants reported that there were times when child caregivers were drawn away to play and neglected their charges.  But for the most part, child caregivers were commended for being very responsible. Some lapidi were considered more neglectful than others, but participants said the same about adult caregivers.  Overall, child caretakers reported that they enjoyed their work and carried out their duties conscientiously and with love.  This was very evident in two of the FGDs conducted in camps with sibling caretakers who had assumed full childcare responsibilities because their adult caregivers had returned to the family village. These child caretakers not only provided basic care, developmental stimulation, and did household chores, but in some cases also worked to earn money or food.  Their lives were filled with struggle, and they themselves sometimes missed out on opportunities for schooling, yet their efforts must be acknowledged for the substantive contribution made to protecting and nurturing the little ones. Participant 1- If our child is sick and if medicine is there in the clinic, then I give them medicine. Facilitator- What if the medicine is not there? Participant 1- I carry the child in my arms or my back. Participant 2- For me I put the child to bed and I lie down beside him. Participant 3- Immediately when our little child is sick I mop his body with a damp cloth if he is feverish. -Two 7-year-olds and one 9-year-old female in sibling FGD  It’s the lapidi who spends the most time with young children.  You find the lapidi all the time struggling with the young child when the mother has gone away to the garden.  Even when mothers are at home, they will want you the lapidi to carry the child.  Even when a child is crying, they will tell you to make the child keep quiet. You struggle with the child until the child sleeps. You carry the child on your back. At times the child wakes up and begins crying again and then they will tell you, ‘bring the child to breast feed’ and when they finish breastfeeding they return the child back to you the lapidi. – 12-year-old girl living in camp caring for her young charge  6.3.3 Community factors that contribute to children’s resilience This section will illuminate community factors that may have acted as protective factors for children, and helped them, as well as families, to cope with very difficult circumstances. The four sub themes which emerged from data are:  1) communal culture and social support; 2) access to services, and; 3) spirituality and religion. Each sub theme will be introduced with excerpts from field diaries that described Okello’s life.   127 Communal culture and social support Field journal notes 7: Excerpts about the role of neighbours in Okello’s life July 6, 2009: Mom says that other neighbour children will help out with childcare: “the children of neighbours are the ones who at times come here to play with him or at times when he is going to touch something dangerous they remove him away from it or remove away the dangerous object. Or at times if he is moving towards a bad place, they carry him and bring him back to a good place” …  December 3, 2009… (Okello) walks alone and has even crossed the road and traveled as far as the mission buildings while trailing other children.  Most people know him so they will bring him back home when they find him.  Although many participants reported that war and displacement had created an individualistic mindset, there was also evidence that people continued to support each other. In camps, when kin were often separated, friends and neighbours became an additional source of support. The excerpts above show that neighbours and their children watched out for Okello and helped to keep him safe.  During our participant observations we witnessed a number of similar occasions.  For example, we observed women offer to take a child to the hospital when their caregivers were working in the fields or too weak to go themselves. What the community is doing here is that they care for the development of the children in relation to good health.  People are so concerned that if a child contracts a disease, they don't care if the mother is present to take care or not, they take up action as a community - so they can pick the child and take the child for injections if money is there.  With his own money he takes the child to the clinic and when the mother comes back it is paid back, and that is good.  It means that there is understanding within the community …. Then if something happens to another person, that person who benefited from the particular effort (in the past), she will be concerned and she will also say ‘I should be able to pay this money because someone else offered it when I was not there…’. Then sometimes if they (caregivers) have gone to the garden, the neighbour will pick up a child that is not hers and take them for immunization - because if the immunization schedule misses the child then they will have to wait for the next time - so that will have helped. They also help people so that they do not die; they say that a child cannot be only for an individual, but also for the government (to everybody) and so they can supervise to see if such a child is doing something bad, or if the babysitter is doing something bad to the child, somebody can easily prevent it.  He can even carry the child away from the babysitter and take good care of him in the mothers absence…. – 25 year old married male, father to 3 children, child protection committee member in return village Some caregivers said that the counsel of both friends and relatives helped them to keep  128 going in difficult times. When caregivers were better supported, they spoke of being able to provide more consistent care to their children. When I lost my husband, I had no one to help.  I didn’t want to talk to anyone.  I just stayed silent.  I thought I was going to run mad- I worried a lot. I stayed in my hut.  I would feel so bad and I would look at the children ‘how a I going to take care of the children?’ I felt defeated.  I would look at people around me doing well and feel so broken hearted; I hated people. When I would sit inside and keep quiet my children would realize it and they would come and sit quietly with me.  The older ones would come and sit and the younger ones would copy them. I would send them to do things like fetch water.  I bought poison and was going to commit suicide.  But then I thought, ‘if I do that, who will take care of the children?’ so I went to my sister who was a born again Christian and I told her.  My sister counseled me and helped me. She kept on coming to visit me, sometimes she would come and spend nights, until I finally started to come out of it.  When I came out of it, the children did too. – 33- year-old mother, inherited by a male relative after the death of her husband, living in a return village after 13 years in displacement The bol chup savings and loan programs described in Chapter four constituted another form of community support. Contributing to a communal pot provided a pool of available funds for group members that could be accessed as need demanded or used to start businesses. Forming work groups was advantageous because workers would rotate their efforts to ensure that all group members’ lands were attended to. These communal activities provided a source of social support to parents, and had positive outcomes for children because resources were available to help meet their needs.  In one community in a FGD of traditional chiefs, they described how the community contributed to paying teachers for their work through communal cultivation of gardens for the teachers: The LCs and the parish chiefs, then they decide on the cost of paying teachers, those  who are helping our children for us....  If money is not there then we help them with digging for each of the teachers… One garden is dug for the teacher where it is expected because he will be struggling for our children. This is what has been happening, it has been happening like that. Access to services Field journal notes 8: Excerpts about services accessed for Okello January 12, 2010: four of the children have been very sick in December and all were admitted in the Pabo branch of Lacor health centre because of malaria and diarrhea. Okello was admitted twice, the lapidi once and the eldest girl twice because of convulsions. When I ask to see their medical forms, Okello had several ailments: severe malaria, diarrhea, UTI (urinary tract infection).   129 February 22, 2010 (in return village approximately 1 km outside of the camp).  Mom feels the rate at which the children fall sick has reduced in the village- it the camp it was constant illness.  Mom brings out Okello’s medical form to show us his recent health issues: Jan 22- started on plumpy nuts (food supplementation) for malnutrition.  He weighed 7.6kg at starting and their target weight is 9.1kg. Feb 8- rashes all over body and cough; Feb 13-17 admitted for 4 days with fever and convulsions, temp 38.1 Celsius, diagnosed with severe malaria, 7.9kg.  The fact that she thinks the children’s health is better is an indicator of just how bad it was in the camp.  The case study of Okello and other examples given in previous chapters indicate that many individual participants and community leaders valued formalized services and viewed them as a protective strategy for children.  Children under the age of 5 were treated for free at the local health centers and hospitals operated by Lacor (a private, non profit hospital with branches in Gulu and Pabo). Given how frequently children were reported to become ill, access to health care undoubtedly saved many of their lives and restored their health, at least temporarily (see Akot’s case study in Appendix A for an additional example). However as has been discussed, many people did not have ready access to services. In sites where they were lacking, the lack was a point of extreme frustration and in all categories of participants, people expressed that this lack was influencing their ability to protect their children: They [the community] feel they should raise up the way of taking care of their children so that they grow up well.  They have struggled to advocate for what their children need but nobody comes to help them; to help them with the problems they have. What have they advocated for that they have not been helped with? Like the issue of the school.  They have written about it.  And then the issue of the health centre, they are so much interested in having it built here and then they also feel that if a project could be brought here so that they begin borrowing from it like a loan [money lending] so that it gives them strength to take care of their children. – FGD with Rwot Kweri from the villages around Omee II  …in our area here our effort in trying to prevent such things [the loss of developmental potential] is that we are trying with our level best to have our children educated such that from time to time we keep on sending our requests to the sub county offices, even to those leaders at the level where they are concerned with education and those who evaluate learning.  Secondly, we are struggling on the issue that they should bring us a health centre, at least one of these small units for helping the lives of our young children.  Thirdly we have also requested of the sub county that if they could accept, they should at least connect us to any NGO who  130 could at least bring us safe water.  This will ensure that our children’s lives will be secured so that they may live appropriately.- FGD with Rwot Kweri and Rwot Okoro, Anaka Sub County. Spirituality and religion The research team did not investigate spiritual practices in depth, but caregivers repeatedly stated that these practices and belief in a higher power gave them strength and comfort in the face of adversity. In the journal excerpt below, Okello’s mother describes how she found salvation from mental illness by becoming a born again Christian: Field journal notes 9: Mom talks about her battle with mental illness and the role of religion April 30, 2010  …. beginning with the time when the war started, it reached a level where my mother’s life was taken, all my sisters were abducted, they were all taken to the bush and we remained merely the young children, just us two, so I started experiencing a very hard life.  Difficulty started coming in my life and what started coming into my mind- I cannot even personally explain it, it has defeated me.  It started like some kind of sickness, and then eventually, it came in the form of something that threatened my mental stability… According to the Acholi tradition as it used to be done and said, performing the traditional rites (was required); they did certain things, they tried it but in vain. Then afterwards, there came some people who were giving advice and they advised me, so I took their advise, I went and got born again and then I became stable in my mind. … When I was with this child, this oldest girl who is now in P4 (grade 4), that is when, say if I had gone to the garden like this, it sometimes occurred in my mind to abandon the child there in the garden and I would come back home, because we were already in the camp in those days.   When I came back home, it may take some time, then I would regain my mind and I would begin to worry and have concern for the child and when the breast would begin to swell with milk, that is when I would remember that ‘oh! I have left the child!’ then I would go back to get her. Would you not find the child crying? Yes, when the child had cried and the child had suffered so much (alone in the fields). But what was really happening was that God was with that child and protected the child.  There was nothing that hurt her body, there was nothing.  As for crying, the child would cry fully.  One day, there was some crawling things on the ground, like those red ants; they were the ones that came and covered her body as they bit her everywhere (her voice shakes). Unfortunately in those days, instead of someone getting concerned and thinking ‘it seems this person is not actually doing it knowingly- this thing is a sickness’, they just never cared about it.  They seemed to think I was doing it deliberately.  But it got to the extent that they began to see with their own eyes, ‘it looks like it is the result of some  131 sickness, or the result of something that happened that is causing this madness’ and that is when they started getting concerned. So what actually helped you to get through the trauma so that now you are free? What really helped me was getting born again (converted to religion)...  Other participants reported similar experiences of faith and prayer.  For example, in chapter 4 section 4.2.2 a mother recounted how she prayed to survive the night with her children after being attacked by rebels.  When caregivers found such support in spirituality, it helped them to continue on in their efforts to meet the needs of their young children.  Additionally, some participants felt that spirituality and religion was a positive protective factor in the lives of young children as was discussed in this FGD with Elder women: I want to talk of issues of spirituality.  We have so many religions here now and many children are attending churches.  Many children love prayers and these are the children who have discipline.  I know there are some children who are not behaving well, but the majority are good. Education and religion has done a lot of good things in people’s lives here.  It has caused a lot of changes.  There are children who used to be thieves but when their parents take them to pray and to school, they change, they are now good children.  6.4 Okello at the end of our year together Between May 2009 and June 2010 when the research team visited Okello and his family, they endured much more than were illustrated in the above journal excerpts. They coped with poverty, multiple illnesses, injury, disability, hunger, violence, theft, land disputes, relocation, and a house fire.  Although each adverse incident caused pain and hardship, they prevailed and successfully transitioned back to their village. When researchers visited the village, Okello’s mom reported that all of her children, including Okello, were free and happy.  The family had access to water, was growing a range of crops, and had built two very nice huts.  They were no longer troubled by the presence of people they felt had been negative influences in the camps and the family once again gathered at the nightly wangoo. Okello’s lapidi started school and was enjoying it, while Okello continued to develop; each time the researchers visited, he had gained new skills.  Okello’s future is yet unknown.   How will the presence of risk and protective factors play out to influence his life outcomes? What would have been different had Okello not lived a life so heavily influenced by war and displacement? Yet this case study can still offer insight into how children can adapt and demonstrate healthy functioning, and families and communities  132 can offer protections to children in terribly adverse circumstances.  The factors that influenced Okello’s positive functioning in the difficult circumstances of camp life included his own lively, determined engagement; the coping ability of his parents; the sharing of roles and responsibilities within his family; the devotion and stimulation of his siblings; his parents goals for his future; the support of neighbours; access to services such as health care; and spiritual beliefs. Unlike other children we observed over the same time period, Okello and his siblings seemed to have an underlying contentment and confidence. Okello was given affection, attention, and the best care possible under the circumstances.  He in turn interacted positively and actively with this environment, smiled, laughed, danced and developed new skills.   133 Chapter 7:  Discussion 7.1 The story behind the thesis In 2007, two important bodies of work were released that motivated this doctoral research. One was the Human Early Learning Partnership’s report on early child development (ECDKN 2007a, ECDKN 2007b) report on early child development for the World Health Organization’s Commission on Social Determinants of Health (Marmot 2005; CSDH 2008). Key messages from this report included the following: the early years are the most critical period in human development; numerous physical health, mental health and social outcomes are strongly influenced by conditions experienced in early childhood; a failure to provide children with nurturing environments not only impacts individual life trajectories but can threaten sustainable, peaceful, equitable development in society; and caregivers require support from government and other agencies (local to international) to create nurturing environments for children (ECDKN 2007a). In the same year, the widely respected medical journal, The Lancet, produced a three-part series on child development in developing countries (Engle et al. 2007, Grantham-McGregor et al. 2007, Walker et al. 2007).  In this series, the authors documented the evidence on risks to developmental potential and concluded that: “poverty and associated health, nutrition, and social factors prevent at least 200 million children in developing countries from attaining their developmental potential” (Walker et al., 2007, p. 145).  Reading these documents led me to reflect upon Uganda, a country I had been working in for several years on a number of different child health projects.  Specifically, my thoughts went to northern Uganda, a region of the country that had been profoundly impacted by two decades of war and displacement.  Given that early childhoods spent in the least nurturing environments manifest the poorest outcomes, then children who were experiencing conditions of war and displacement were likely to be amongst the most vulnerable. However there was a dearth in the research for children under 5 years living in such contexts (Walker et al., 2007). Organizations serving northern Uganda had documented some of the short-term health outcomes experienced by young children, which have been referenced throughout this thesis. These findings were undoubtedly important as they demonstrated high levels of morbidity, mortality and poor nutritional status but they revealed little about the complexity of the situation.  That is, they did not address the questions of ‘what’, ‘why’ and ‘how’ (Green & Thorogood, 2009) environments characterized by war and displacement act on young children.  To me, it seemed that gaining a deeper understanding  134 of these impacts was critical to those who aim to address and ameliorate children’s vulnerability in the least nurturing environments.  Further, in some way I wanted to give voice to young children. …lack of voice for young children occurs at all levels, from the local to the global.  In communities, younger children are likely to be less visible and are therefore more difficult for service providers to identify.  Schools are often a primary focus of interventions and a means to identify children in need, but the youngest children are not yet in school and therefore do not have access to school-related responses. (Fonseca et al., 2008, p. 105). The infants and toddlers living in northern Uganda were not aware that they were living out the most critical phases of their lives in the aftermath of war, but the scientific community and global policy makers were.  Yet for all of the available evidence documenting the importance of early childhood, researchers and organizations were paying insufficient attention to this hard-to-reach and highly vulnerable population. I therefore embarked on my thesis project with the objective of connecting the science of early childhood, with the realities of life for the children of northern Uganda, and in doing so, advance a case for action.  7.2 Synopsis This doctoral research took a continuum approach to exploring the environment of early childhood by comparing the past to the present in order to capture the impact of war and displacement. In addition, the research sought to contextualize concepts by exploring the study population’s meaning of risk factors, protective factors and their outcomes (Ungar, 2005). The examples of risk and protection discussed in this thesis come from the Acholi context and Acholi respondents. The experience of risk and protective factors ebbed and flowed in the temporal context of pre- war, war and displacement, and resettlement: 1) pre- war, rural agrarian living was perceived as an environment of relatively low risk and high nurturance (high in protective factors), 2) as violence and displacement increased over the course of the 20-year war there was a steady increase in risk and decrease in nurturance, and 3) when war ceased, the experience of high risk conditions persisted for several years followed by a very gradual decline as people re-settled in their villages (if they were able to do so) and began to re-build their lives and re-create nurturing conditions.  This continuum is depicted visually in Figure 7.   135 Figure 6: An illustration of risk and protective factors experienced during and war and displacement   Collectively, there are four major threads that reflect the key findings presented in chapters 3 through 6: • War and internal displacement are highly damaging social determinants that threaten young children’s health and developmental potential. • The cessation of hostilities and formal end of displacement leads to a difficult and prolonged transition phase in which risks persist. • Protective factors and healthy functioning existed amongst the very difficult circumstances of war, displacement and recovery. • Efforts to address early childhood in war and displacement were insufficient and incommensurate with the degree of available scientific evidence documenting the critical importance of early childhood.  Each thread is discussed in turn.     136 7.3 Thread 1: War and displacement are highly damaging social determinants that threaten young children’s health and developmental potential The infant’s development is inextricably tied to the care that surrounds it. In the same way, the care that caregivers provide is dependent upon the nature of the surrounding stresses and supports… When one grasps the critical importance of contexts, the pointlessness of blaming parents is immediately obvious (Sroufe, 2005, p.354) War and displacement are social determinants that act upon young children by two primary ways.  Firstly, they inhibit caregiver’s ability to apply typical childcare strategies that nurture and protect children.  Secondly, they produce daily living conditions that expose young children to numerous, cumulative risk factors.  7.3.1 Traditional protection strategies thwarted Children are highly dependent on others in their first years of life.  Hence there is a presumption in current policy and practice guidelines that families will protect and nurture children towards positive life outcomes - if they remain united. This belief is reflected in policy documents such as the United Nations Resolution Guidelines for the Alternative Care of Children (UN General Assembly, 2010) and the Inter-agency Guiding Principles on Unaccompanied and Separated Children (Inter-Agency, 2004). Indeed, as was highlighted through participant’s retrospective narratives of life before war (presented in chapters 3 and 4), under typical circumstances Acholi caregivers will fulfill such expectations. However, as noted by Wessells and Edgerton (2008), in war zones “the damage to children occurs in no small part because war shatters many of children’s existing means of protection” (p.4).  In northern Uganda caregivers possess many strategies to nurture and protect children. Families not only ensured that their children’s physical needs were met, but also that the children learned and practiced the social-cultural values and livelihood skills that would enable them to become successful adult members of their societies once past the period of dependency (LeVine, 1977 in Marfo, Biersteker, Sagnia & Kabiru, 2008). However, as Ager (2006) proposes, while family is fundamental to existing understandings of children’s welfare, such emphasis may prevent adequate consideration of other social ecological forces acting on children. The participant narratives presented in this thesis reveal how their protective strategies were greatly inhibited or thwarted altogether when war struck the region and they were forced to leave their homes and regular lives (see figure 7). Consequently, merely ensuring the families stay together is not enough to ensure children’s well being; families require support to meet their children’s needs in environments such as  137 war where nurturance is compromised.  Figure 7:  Changes in risk and protection from peace to war.  7.3.2 A gap in protection strategies that cannot be filled The erosion of traditional strategies was compounded by the very few protective strategies gained in camps to help them to nurture, provide for and protect their children. As shown in figure 7, greater access to (and the corresponding greater valuation of) formalized education and health care was an exception to this.  Yet, despite the advantages of access to these resources, the health of both adults and children deteriorated due to the social and physical living conditions of displacement. The food distributions that relief organizations provided as a protective strategy could not compensate for the lost quantity and variety of foods produced in their villages prior to wartime. Further, there was a mass descent into poverty that often prohibited people from accessing minimally available services such as nursery schools and day cares. Such services that were sometimes provided by organizations at low to no cost were insufficient to meet the needs of the thousands in the camps, as they were not scaled sufficiently and/or some were not adequately monitored and sustained.  The end  138 result was a net loss for young children. Despite the aid provided, the circumstances in the camps prevented caregivers, families, and communities from adequately protecting young children  7.3.3 The accumulation of risk Further multiplying the issue of eroded traditional protective strategies and lack of compensatory services was a simultaneous and substantive increase in risk factors faced by young children. Chapter 3 highlighted the physical threats to young children’s health and development including conflict-related violence, malnutrition and poor health. Poverty featured prominently in all participants’ reports on what made children vulnerable to having lives riddled with risk. It also underlay the other factors which were identified a compromising the care of children. Prior to the war, the Acholi people were not wealthy by international standards, but village life provided a relatively stable social and physical environment, sufficient for sustaining healthy development.  However when war and displacement struck the region, it brought absolute poverty, defined as  “...severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education and information” (Gordon, Nandy, Pantazis, Pemberton & Towsend, 2003, p. 5).  Essentially the level of poverty brought on by war and displacement was a crippling social determinant that at times brought children naked, hungry, sickly despair.  Chapter 4 illustrated the social threats to children’s well-being that arose due to the conditions of war and displacement: familial separation and lost family members; being orphaned; neglect; and domestic violence.  Further, the very camps that were intended to protect people, subjected children to numerous negative social influences by individuals and groups, often in the absence of caregiver mediation. Participants described how when children’s needs went unmet and risks were experienced, particularly when it was excessive or prolonged, there could be negative consequences. Drawing upon their lived experience, they talked about health and developmental outcomes in both the present and future. Although their language differed, their perspectives on what constitutes risk showed high concordance with the research evidence described in the introduction section. Moreover, their reports about the existence and abundance of such risks to children corroborate other research conducted in the area (Dolan, 2009; Kostelny & Wessells, 2008; The Republic of Uganda et al., 2005).  139  Although participants were aware of the risks faced by their children, the daily realities of life in the camps often prevented them from mitigating those risks.  As the case study of Akot (appendix A) illustrated, the child was neglected due to a cumulative mix of terrible circumstances. Caregivers and community leaders for the most part wanted to nurture, provide for and protect their children, and did so to the best of their ability under very trying daily living conditions.  However, their efforts were frequently reported to have insufficient impact and sometimes even created further risk. For instance, participants who went to work in order to meet the family’s basic physical need for food were forced to leave young children unattended in uncontrolled and sometimes hostile environments. This forced prioritization due to overwhelming and untenable life circumstances also diminished the attention given to higher-level child development goals, such as socialization and productivity; a finding noted by other researchers such as Marfo et al. (2008). War and displacement forced such prioritization on a large scale, thereby affecting entire communities.  Caregivers’ loss of control over children’s lives and outcomes was to a large degree the product of the widespread structural violence that both created and perpetuated the war. Structural violence has been described as the ubiquitous and insidious political, economic, cultural, religious and/or legal social structures that prevent people from attaining full potential, by impairing their ability to meet needs (Galtung, 1969 in Farmer 2006).  Dolan (2009) described the war in northern Uganda as “a situation whose primary function was social torture rather than war” (p. 110) because the prolonged displacement of civilians constituted a mass violation of human rights, including rights to health, education, livelihood, and protection.  The camps were ostensibly created to offer protection to children, but in reality, they created more risk. The structural violence was so pervasive that participants could not meet their children’s most basic survival needs such as for food.  Understandably, the participants’ experiences of structural violence elicited sentiments about lack of control, pain, and worry.  Fatalistic sentiments about the futures of children raised in the camps were common. Statements like “This is not going to be a good generation” or “our children have all been spoiled” were heard frequently throughout the year the research data were gathered. While we cannot and should not characterize this population solely by risk and ignore their capacity for adaptation and resilience, there is  140 clearly reason for grave concern for these young children.  The environment escalated the accumulation of multiple risk factors experienced over a prolonged period. War and displacement are thus social constructs that create the conditions for large-scale loss of developmental potential.  7.4 Thread 2: The cessation of hostilities and formal end of displacement leads to a difficult and prolonged transition phase in which risks persist In the aftermath of northern Uganda’s vicious 20-year war, caregivers and communities struggled to rebuild their way of life, which would enable them to ensure their children’s well- being. As they sought recovery from more than a decade of displacement, the major resource available to facilitate their transition home was their hard, prolonged labour. Agricultural lands and homesteads that had resorted to bush land had to be cleared, replanted and rebuilt.  Caregivers who engaged in this labour were eager to remove their children from the camps and resume traditional childrearing practices. They longed for the time when life would be much like it used to be – characterized by locally produced resources such as food and livestock and a positive, controlled environment for children who were surrounded and nurtured by family. Sadly, through the difficult process of transition, participant’s reported and researchers observed environments that were not supportive, safe or nurturing for young children. The structural violence that had prevented them from meeting their children’s basic needs during the war persisted into resettlement.  Aid to facilitate their effort to return home was often lacking leaving children without a safety net. Access to resources such as health care, education, clean water, roads and other services was reported to be unavailable or limited for most study participants when they returned to their villages. Organizational reports issued during time of this study corroborated participants experiences indicating that the phase-out of conflict-focused humanitarian activities was not well synchronized with development activities (i.e. re-building infrastructure, services), leaving a gap for the people trying to return and rebuild (NRC, 2010).  The Government of Uganda’s (GoU) Peace, Recovery and Development Plan (PRDP) promised assistance to help bring the standard of life in the north up to the national standard in terms of indicators such as education, health and economic status, but the promises were slow to materialize, if at all.  A 2008 review showed little achievement from this ambitious plan owing to funding and implementation issues (Beyond Juba, 2008). A briefing paper by  141 the Norwegian Refugee Council in 2010, noted that implementation of the plan did not commence until July 2009 and that the government ultimately committed to funding only 30% of the original budget, requesting the remainder from the international community. This funding from the international community was also slow to materialize.  Thus the aftermath of war brought continued vulnerability to the youngest members of society who continued to experience numerous risks to their health and development; including malnutrition, poor health, and survival based neglect in the form of reduced care, supervision, teaching and stimulation. As was the case during active conflict, as risks accumulated for children, so did the concurrent threat to children’s cognitive, social- emotional and/or physical well-being.  Yet as Wessells and Edgerton (2008) have highlighted, such accumulation of risk is typical for too many children both during and after war.  Families who had resettled for longer periods reported a slow improvement in family resources, which was accompanied by the restoration of factors that promoted children’s health and development.  These factors included increased parental supervision, fewer negative social influences, increased food security, and the “joy” and “freedom” afforded by the village life; it is salient to note that access to services was not one of the reported factors. To the contrary, families who were not able to progress through the phases of transition and resettle in their villages remained ensconced in the problems of camp living, and had to cope with the added burden of the cessation of services.  They reported greater amounts of suffering for their children.  Although participants had different post-war circumstances, they shared a common experience of dealing with reduced social and economic capital in the wake of war. Thus, children remained highly vulnerable to adversity and risk when faced with post-conflict challenges such as lack of services in return sites; the arduous and prolonged process of relocation and rebuilding; or continued disenfranchisement.  7.5 Thread 3: Protective factors and healthy functioning existed amongst the very difficult circumstances of war, displacement and recovery Children who recover from a period of adversity or maladaptation have either a solid foundation on which they can rely, increased supports and decreased challenges, or, more often, both. (Sroufe, 2005, p. 364).  142 Although the children in the study were exposed to a myriad of risks, there were examples of positive adaptation under very trying circumstances. The Acholi viewed children as active learners who functioned as agents of their own development within a supportive web of kin. This perception supports the literature on ECD in Africa, which reveals that in many contexts daily routines (e.g., self-care, family chores and duties) are used to educate children and that children progress through tacit stages of learning by assuming different roles in various settings (Nsamenang, 2008).  There is an assumed level of competence within children that allows them to extract the skills and knowledge that they require to teach themselves under the guidance of peers or family (Nsamenang, 2008).  This drive to learn and develop within the prevailing relational and contextual circumstances was evident in the harsh context of camp living. As described by Triplehorn and Chen (2006) “Children are at the centre of their own protection. In conflict, children are not passive victims but active survivors” (p. 225). While camps were so grossly unfamiliar to the rural agrarian way of life, the camp environment was all that children born in war knew and they adapted to it in ways meaningful to their development. In turn, their environments and experiences were literally shaping their emerging brain architecture (National scientific council on the developing child, 2007). Boyden and Mann (2005) call for recognition of children as social agents who make legitimate efforts to cope with adversity, and thus, whose voices should be heard to inform solutions to the problems that impact them.  While the young children of this study were too young to contribute their voices to this research, they too have much to teach about actively coping with adversity through their actions.  They display many of the traits deemed protective in older children: curiosity, adaptability, helping others, resourcefulness, and actively trying to take control of their lives (Boyden & Mann, 2005).  Unaware of the wide- open spaces of village homesteads, they ran, played and learned new skills in the dirty, confined spaces between camp huts. Separated from kin, they found friends, playmates, instructors and guides amongst strangers. When their caregivers were away during the day, they traveled through the camps in packs of children, as this was the social network available to them. When they were hungry and no sustenance was available they learned to steal food, or to scavenge through dregs of washed dishes at eating joints to fill their empty stomachs. The trash of the camps also became their toys. In the absence traditional dances and songs passed down by families, they seized opportunities to learn songs from the radio, hymns from the churches and practiced dancing “disco” shaking and rolling their hips. They even emulated behaviours seen on the silver screen, which they watched as they piled on top of each other to peek into video halls. For young children, this was their environment  143 and through their instinctive and active pursuit of new learning and developmental progression, they adapted.  From the time children were ambulatory, they had much more freedom and autonomy than they would have had in the villages. Thus, in the camps, peers, older children, adults (both kin and strangers), media, schools, NGOs and international organization workers contributed substantively to the socialization of young children.  This process often occurred without the mediating role of primary adult caregivers. The plurality of socialization forces combined with children’s elevated autonomy diminished the centrality of the family (Ager, 2006). Adults who had known traditional village life often expressed disapproval of the new behaviours and qualities that children adopted lamenting that the camps had spoiled their children. They feared for their children’s futures living lives so far removed from the quiet, controlled rural lifestyles of past.  However, taken in context, young children’s adaptation to camp life was both meaningful and purposeful. Whether camps “spoiled” children may be a matter of perspective.  Camps likely did substantively alter young children’s developmental paths and in some ways made them strangers to their families and traditional culture. But viewed as an adaptive response to a difficult and grossly atypical social context, the changes in children can be viewed as healthy functioning that may contribute to their long- term resilience.  Resilience is subjective and as such, perhaps some of these individual children were embodying resilience, even as they were perceived as embodying vulnerability from a broader social stance (Kaplan, 1999 in Unger, 2005).  Caregivers also had to cope with and adapt to the camp environment.  They, too, exhibited an inspiring persistence in trying to protect their children.  This persistence may have been linked to the demands of the caregiver role. Primary caregivers simply could not be rendered dysfunctional by illness, hunger, fatigue, despair, or the limiting conditions of their environments because their children needed them. Thus when they needed to perform intense labour in order to meet their children’s basic survival needs, they did it - both during and after conflict (McElroy, Atim, Spittal, Muyinda & Backman, 2011). As other research indicates, women played a crucial role in post-conflict reconstruction as they carried much of the burden of protecting and providing for their families (Sorensen, 1998). Some of the positive and perhaps protective strategies used by caregivers of the youngest children included the hard, prolonged, physical labour to feed, clean, clothe and care. Their loving attempts to offer soothing and comfort to infants with the snuggled closeness of back-  144 carrying, a warm lap to sit on, or the offer of a breast were widely observed; practices that also promoted children’s attachment. In the midst of war, displacement and recovery, there were many moments of shared love, play and caring, and these must be appreciated for the protection they offered children mentally, emotionally, and physically.  Research demonstrates that when caregivers cope well, it is predictive of their young children’s resilience (Laor et al., 1997; McCallin, 1996; Zivic, 1993 in Ager, 2008). Access to social support appeared to contribute to the positive adaptation of both caregivers and children. Support came in many forms and was provided by spouses, children, extended family members, friends, neighbours, and formal institutions and services. This finding supports the literature pertaining to children in war describing the importance of nurturing, supportive social relationships and interactions on multiple levels (Kostelny, 2006; Triplehorn & Chen, 2006). Finally, there was evidence that believing in a higher power and praying gave some caregivers the strength to carry on in the uncontrollable and sometimes horrendous circumstances of war and displacement. This too promoted positive coping and adaptation so that they could work for and care for their children, in keeping with the findings of other researchers in different conflict contexts (Kostelny & Wessells, 2008; Triplehorn & Chen, 2006).  In this study, the families who did not have social supports consistently reported the most hardship. It was in these families that fellow children assumed the heaviest responsibility in caring for the infants and toddlers. Sometimes these child caregivers were themselves only a few years older.  This finding is congruent with research demonstrating that the amount of work sibling caregivers take on within families tends to correlate with amount of work the mother must do to sustain their families economically (Harkness & Super, 2002; Weisner, 1977).  In the contexts of war and displacement children’s responsibility for caring could reach beyond traditional or typical to levels deemed considerable and even onerous (Becker, 2007). Nonetheless, while child caregivers raised a number of important issues about their own vulnerability, they also demonstrated that they were highly resourceful and responsible. They therefore merit much recognition for the roles they played and the sacrifices they made in contributing significantly to the protection of the very young. Their situation highlights a need in displacement and resettlement to expand the focus of the education sector in supporting and providing routine to school-aged children.  Young children and their child-caregivers also require a safe place to be together where their  145 relationship and bond is valued and their needs are holistically met. This approach of offering child friendly spaces is being trialed with positive results (Kostelny & Wessells, 2008) and deserves greater attention and scale up.  When considering policy and services that can meet children’s needs in war and displacement contexts, it is important to recognize positive adaptations and the factors that offer protection. If services can be targeted to support these factors within the restraints of limited resources and the environment, the well-being of children, caregivers and communities may be better served. At this point in time we cannot know how these children’s lives will play out or the long-term impact of growing up in war and displacement. Nonetheless in the horror of war we should be rendered hopeful by a young child’s persistent engagement in enthralling, joyful play; by the devoted love and toil of caregivers; by informal networks of support; and by the determined advocacy of leaders.  7.6 Thread 4: Efforts to address early childhood in war and displacement were insufficient and incommensurate with the degree of available scientific evidence documenting the critical importance of early childhood  The introduction to this thesis outlined the vast and growing body of evidence that addresses the critical importance of early childhood. The strength of this evidence has led to policies and interventions that strive to meet the unique needs of early childhood and mitigate risks to healthy development.  International bodies such as the United Nations, the World Bank and the World Health Organization have called upon National governments to increase attention, training and spending for early childhood development (ECD) in order to create holistic, accessible and indigenized programs are based on partnerships with families and communities (Prochner & Kabiru, 2008).  Progress is evident in the significant presence which ECD has recently gained in international policy such as the World Declaration for Education for All (UNESCO, 1990), the Convention on the Rights of the Child (UN, 1989), The African Charter on the Rights and Welfare of Children ACRWC (1990) (Aidoo, 2008); and the Organization for African Unity’s ‘Africa Common Position: Africa Fit for Children’ (African Union, 2007).  ECD priorities have also been included in major global targets for development: the Millennium Development Goals (MDGs) and Education for All (EFA) (Jaramillo & Mingat, 2008).  Nonetheless, the  146 calls for action are insufficient if they cannot or do not address the interests of children who are difficult to reach and exposed to environments with high levels of risk.   Unfortunately, this study and others provide examples of situations in which such efforts have fallen short of meeting children’s needs (Boyden & de Berry, 2004; Machel, 2001; Triplehorn & Chen 2006; Wessells & Monteiro 2008). As noted in a report on early childhood produced by the World Health Organization’s Commission on Social Determinants, families need support and sustained commitment from regional, national and international communities in order to provide nurturing environments for children and preserve developmental potential (ECDKN, 2007a). This is particularly critical in high-risk environments where structural violence inhibits caregivers’ ability to nurture the very young. As has been emphasized, the participants in this study reported that both the state and external actors failed to give them the support they needed to properly nurture their children (during and following the war).  This failure points to a continued need for governments, international organizations and NGOs to further develop policy and programs which meet the needs of young children living in conditions of war and displacement. Alternatively or at the same time, this failure may reveal that the implementation of programs is beset by serious problems. Although the challenges of providing support to children living in conditions of war and displacement are numerous and onerous (Wessells & Edgerton, 2008), the potential long-term risks of not doing so for both children and society are too serious to forego.  In northern Uganda, risks to young children in displacement and the post-conflict resettlement phase could have been mitigated to a much higher level. The experiences of these children can and should inform better approaches in the future. Targeting is required at both the macro levels to rebuild communities and environments that support and enable children, and at the micro levels to directly address the needs of individual children (Wessells & Edgerton, 2008).  Examples are included in the recommendations that follow.  Post conflict development support:  Participants experiences in this study demonstrated a clear need for continued support from aid and government organizations beyond conflict end. The support provided by organizations should focus on bolstering families and communities and (as suggested by Wessells and Monteiro, 2008) promote the reacquisition of control and efficacy at the personal and collective levels. This study demonstrated that participants were generally aware of young children’s needs and risks, but were prevented from addressing these risks and needs by poverty or other debilitating barriers. When  147 organizations withdrew support, the risks face by children grew because many families were not yet self-sufficient. A gradual withdrawal of services that is responsive to the rate of transition may be more successful in sustaining child development.  Health and nutritional vulnerability: Participants frequently reported and researchers observed, that children were malnourished and vulnerable to disease during both displacement and post-conflict transition.  There was a clear need for health and nutritional programming to continue for a longer period of time when conflict ended in consideration of the prolonged time required to rebuild rural agrarian livelihoods.   When food aid ceased, there were categories of “extremely vulnerable individuals” (EVIs) targeted for extra food aid, however, reports and observation suggested that young children were not amongst them. The available nutritional services were based in health centers and hospitals and intervened when children were already seriously malnourished; little was done to maintain nourishment/prevent illness.  Although continued dependence on food aid is not a desirable outcome of programming during resettlement, it also must be acknowledged that young children’s brains and bodies are particularly vulnerable to nutritional deprivation and that long-term outcomes can be serious (Walker et al., 2007, 2011).  Targeting young children, breast-feeding and pregnant mothers as categories of ‘EVI’ merits further consideration.  Addressing survival and moving beyond: Attending to basic health and nutrition is essential for young children, but there is also a need to think forward to long-term outcomes. If the goal is to contribute to the preservation of human capital and the reduction of negative long- term health and social outcomes over the life span, programs must look beyond survival in ensuring that children have the opportunity to truly thrive.  For example, while policies exist to address the separation of children from caregivers in war zones, this did not fully address the situation faced by caregivers in northern Uganda.  These caregivers had to leave their children behind in camps without adequate childcare while they went to work.  This was the case during active conflict and even more so in post-conflict when they returned home to prepare for resettlement. The outcomes for young children in these situations are similar to separated children - long periods of time without the protection, care and attention of a primary caregiver and exposure to a myriad of risks from the social and physical environments. Therefore findings of this study clearly suggested a need for culturally appropriate childcare solutions both during and after conflict to protect and nurture children left in camps unsupervised. This finding corroborates a study conducted in the Gulu District  148 of northern Uganda prior to program implementation by Kostelny and Wessells (2008).  Solutions for providing ECD care in war zones may be found in the poverty-reduction strategies already being employed at the grassroots village level in northern Uganda such as in cooperatives of rotating caregivers, or the trade of goods and/or labour for childcare services. Early Childhood Care and Development programs, or child friendly spaces, were implemented during the conflict period both in the Amuru district, and other affected northern Ugandan districts (Kostelny & Wessells 2008). These interventions were well received by families as well as community leaders and had positive outcomes for young children. However, reports suggested they were not scaled sufficiently to meet the needs of the population, were often not monitored and adequately sustained, and were not maintained in the post-conflict period, which left a major void.  Participant observation during post-conflict revealed that there were numerous peace and development strategies that were targeting adults and youth. The neuroscience introduced earlier indicates that such interventions may be beginning too late to have the desired large- scale impact, because the roots of these social issues are in early childhood (Contreras et. al., 2011; Fox & Shonkoff, 2011; Glaser, 2000; Margolin & Gordis, 2000; National scientific council on the developing child, 2007; UNICEF, 2006).  While there is certainly benefit to such programs, they have the potential for much greater impact if they devote at least equal attention to helping communities establish nurturing environments for young children and target the formation of peaceful relations from infancy.  Facilitating children’s resettlement and resources in return sites: The findings suggest a need to proactively implement innovative ways of reaching dispersing pediatric populations who are re-settling after displacement. Participants indicated that many lacked accessible healthcare, clean water and early childhood education interventions after they returned home.  Grassroots research is required to guide the planning and monitoring of such essential services and ensure that the realities and most pressing needs of those who are dispersed and hard to reach drive the solutions.  When commitments are made and services are implemented that reach communities, greater attention and action is required to sustain programs and/or find realistic solutions for transferring them to local government or communities.  The participants of this study expressed great frustration and disappointment over having programs introduced only to see them fail shortly thereafter due to a lack of  149 monitoring and on-going support. Money invested in services that fail or only target a limited, centralized population will not reach the many whose needs are great, indicating that the allocated monies could be better directed.  In northern Uganda, services such as immunization outreach were reporting success, yet such remote out-reaches were perhaps under-utilized as a means of providing additional decentralized services that address children’s health.  Interventions such as Child Protection Committees or Village Health Teams working at the community level offered tremendous promise in meeting young children’s needs.  The teams that implemented these services at the community level were highly knowledgeable about the risks children faced.  However, when they were given minimal to no follow up support to address the risks they identified it became an exercise in frustration, work diminished and children lost this resource. Implementers need monitoring and evaluation researchers need to gather evidence as to whether or not interventions are succeeding, as well as why or why not.  Additionally, implementing organizations need the commitment and flexibility to be responsive and to follow-up by taking action on the issues identified.  7.6.1 Making the science match the intervention The intention of this research was to advance an understanding of the ways in which war and displacement affect young children’s health and development. Young children are the most vulnerable to deprivation of their environments because of their high level of dependency and the rapidity of developmental change that occurs during the early years. Economists have affirmed that based on the scientific evidence available, investing in the early years is the most potent investment a state can make. It multiplies returns across the lifespan in terms of productivity, health and social outcomes (ECDKN, 2007a, Young & Mustard, 2008). If the opportunities for development are missed in early childhood, more resources and more time are required to produce a thriving life course (ECDKN, 2007a, Young & Mustard, 2008) - resources that are often not available in low-income countries. Yet for all of the evidence, in northern Uganda the efforts to address early childhood both during and after war were insufficient.  Researchers’ observations showed the youngest children were often targeted less than other higher profile groups such as school-aged children, youth, child soldiers and the formerly abducted. This targeting is incommensurate with the degree of strong science supporting early childhood.  Thus in moving forward, there is a great opportunity for program planners and policy makers to pay heed to the science of early childhood and to implement programs that have powerful long-term impact.  150  7.7 Directions for future research This exploratory study sheds light on factors that threatened the developmental potential of young northern Ugandan children living in conditions of war, displacement and post-conflict transition. As such, it offers a basis for further research.  A potential direction for such research would be a long-term study of outcomes for children who have spent their early childhoods in war-torn environments and/or conditions of displacement.  This research would offer considerable insight into resilience, which is not a trait, but a developmental process that occurs over time and is determined by a multiplicity of changing factors. Consequently, it is best investigated by a longitudinal study methodology (Cicchetti, 2010).  7.8 Comment on strengths and limitations of thesis research 7.8.1 Limitations This study describes in-depth the experiences of people living and transitioning from three camps in northern Uganda.  The extent to which people living in other northern or urban districts shared the experiences of the study participants is therefore unknown. Even within the target population some important caveats should be noted. First, the timing of the research was such that many of the participants were among those who stayed longest in the camps before resettling.  They may have faced greater challenges than people who resettled earlier.  The cross-sectional study of people in different phases of resettlement helped minimize, but likely did not overcome this bias.  Secondly, while the case study methods offered a longitudinal perspective to an extent, much of the data were cross- sectional and captured a moment in time. Long-term follow up would offer a broader perspective on outcomes for children. Thirdly, two researchers conducted participant- observations, so their positioning will differ from that of other researchers. Nonetheless, a degree of rigor in the analysis and interpretation of findings was assured because of the application of multiple forms of triangulation, the audit trail that was maintained, and their participation in debriefings with other research team members. Fourthly, there may have been a recall bias in the retrospective accounts.  Lastly, while participants were told in the informed consent process that there were no programmatic benefits from participation in the study, because the population has grown accustomed to service delivery, there may have been some attempt to present the needs of the child, family, community in such a way as to elicit services or other assistance (Harrell-Bond, 2007). The research team perceived these requests as evidence for the population as being “people with agency and voice”, rather  151 than passive victims of their circumstances (Eastmond, 2007, p. 253) who used the research setting to act, to convey a message about community needs and have the researchers confirm that the message would be passed on.  Participants may have told researchers what they thought was desirable, for instance, under-reporting the use of traditional healers and herbs.  Extensive exposure to health education in camps may have lead many to be aware of what western researchers wanted to hear.  The relatively large sample, range of data sources and volume of data helped to mediate any systematic respondent bias. Similarly, others may have answered questions in such a way as to portray themselves in a favourable light. On more than one occasion participants talked about their care-giving roles or practices in a positive or complimentary manner only to have members of their community later contradict their reports to us (in private and confidence).  For instance, one male respondent spoke openly denouncing violence between spouses as a practice that makes life difficult for the children, however, others in the community confided to us that this man regularly practiced violence in his home to the point where his wife and children are forced to flee for their safety.  As can be seen in this example, method triangulation (also using participant observation) assisted the team to recognize this bias when it occurred, and provided additional information that presented the situation in its full complexity.  Another means of dealing with this bias was through revisiting the same respondents and/or sites over time.  The case study method was particularly vulnerable to researcher reactivity as described by Jacobsen and Landau (2003) because of the high vulnerability of children living in internal displacement camps, particularly after the cessation of food aid. The team advocated on behalf of several of the children in this research eliciting services such as health care, day care and assistance with repatriation.  In these situations, the team agreed with stance put forward by Mackenzie et al. (2007), deeming it unethical to remain ‘objective’ and not intervene for the health and indeed survival of young participants. The research team acknowledged that their reactivity had altered the situation for the participants and consequently altered research findings.  7.8.2 Strengths This was an exploratory study that used qualitative methodology to shed light on an important and neglected area of research.  The study captured depth and breadth of  152 information by engaging both a cross sectional sample to explore various phases of post- conflict transition and longitudinal case studies.  Secondly, though it meant that much time was spent on travel, the researchers ensured that very remote participants were included in order to capture their unique issues. This was particularly important for understanding context and perspectives because the region is primarily composed of rural agrarian people. Thirdly, the sampling approach recognized the broad social environments that impact young children, and thus did not privilege primary adult female caregivers alone in sharing insight. A large, diverse sample ensured that multiple important perspectives were included. Fourthly, numerous strategies were employed to advance study rigor. For example, triangulation was used in multiple ways (researcher, method, site) to enhance the study’s trustworthiness.  Furthermore, the extended period of fieldwork allowed time to collect data thoroughly, re-visit sites or situations that required it, and confirm emerging findings. Copious field notes and photos supported the audit trail throughout data gathering and analysis. Attention was paid to important details such as ensuring the accuracy of translations.  Fifthly, ethical considerations were thoughtfully considered and local fieldwork teams, supervisors and committee members were consulted when decisions had to be made about how to proceed in the field.  Finally the researcher endeavoured to ensure that the research gave back to the community through feedback sessions, and advocacy was done on behalf of individuals and communities.  This resulted in tangible benefits to some participants.    153 7.9 Conclusion There are approximately 26 million internally displaced people in the world. These are people who remain within their own countries but who have been forced to leave their homes due to conflict, human rights violations and/or generalized violence (UNHCR 2008). Africa is the continent most impacted by internal displacement with an estimated displaced population of 11.6 million, approximately half of who are children (UNHCR 2008). These children have been removed from their home environments and denied the social supports that provide them with routine and nurture during the most critical stages of their development. As this study has demonstrated, war, displacement and its aftermath have profound impacts on young children and create conditions of significant risk that threaten developmental potential.  Although the policy and resource foundations to meet needs have been laid, more must be done to tangibly assist those living in the most difficult environments who are the hardest to reach and the most vulnerable. There is significant room to build upon factors that promote resilience, to facilitate caregivers in meeting their children’s needs and to help restore nurturing environments to preserve human capital. Failure to do so jeopardizes the future of a healthy prosperous society.  Societies impacted by war desperately need to preserve the human capital that will ensure their future is better than their past. As the 2011 World Development Report on Conflict, Security and Development states: No low-income fragile or conflict-affected country has yet achieved a single MDG (Millennium Development Goal). People in fragile and conflict-affected states are more than twice as likely to be undernourished as those in other developing countries, more than three times as likely to be unable to send their children to school, twice as likely to see their children die before age five, and more than twice as likely to lack clean water. On average, a country that experienced major violence over the period from 1981 to 2005 has a poverty rate 21 percentage points higher than a country that saw no violence… (p. 5) Put simply, health, peace and development cannot exist without a healthy thriving human population and a thriving human population cannot exist without healthy, peaceful, thriving children.  154 References Accorsia, S., Fabiania, M., Nattabib, B., Corradob, B., Irisob, R., Ayellab, E.O., et al. 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We asked some children in a nearby home about her and discovered her caregiver had gone to the fields for agriculture work.  July 13, 2009: We returned again to find the child had been admitted to the referral hospital outside of Gulu town.  An aunt who was around told us the child had been abandoned by her mother who had eloped.  Her father had placed her in the care of his sister, who was now with the child in the hospital.  July 22, 2009: We returned again and again found Akot alone sleeping curled up outside in the dirt facing a wall.  She looked at us when Stella greeted her, but did not respond and then turned back to the wall.  We persisted, coming again later in the early evening and were pleased to find her seeming much more lively as she sat eating roasted maize with her aunty next to her.  We noted that she may have a physical impairment as her legs were in full extension and adducted. We told the aunty of how we kept finding the child alone, malnourished and ill and had considered reporting the case to the authorities out of concern for her well-being.  Aunty told us of how she had no choice but to leave the child, Akot, all day because she could not carry her on her back to the fields, owing to her own sickness and chest problems. Aunty is a 40-year-old widow whose husband was abducted in the war and never returned. Her own children (who traditionally would have assisted with care) were grown and had moved away and the one teenage boy who remained at home was not willing to care for Akot.  Aunty told us of how Akot’s mother abandoned the child in her first year (she was now 2 years 8 months) and the child’s father provided almost no support. The child was sickly and just last week they went to the hospital for treatment of malaria and diarrhea.  They were told at discharge that Akot needed to be admitted to the therapeutic feeding centre to deal 168 with her malnutrition, but the aunty was too unwell and unprepared for a lengthy stay; she promised to return when she was better.  We offered to transport Akot and her aunty to the hospital the following day, and she consented.  July 23, 2009:  The next day as we traveled to hospital, Stella talked to the aunty.  She told us of how Akot really suffered in her early life when she was abandoned. The father kept her after her mother left but he did not care well for her and when he finally brought her to the aunt she was very malnourished and sickly.  She suspects Akot’s early neglect/ suffering was what caused the physical impairment (increased muscle tone in the extremities- legs in extension, arms in flexion- worse on the right side, likely a neurological insult from malaria or some other infectious disease).  Akot’s father remarried and his new wife did not want Akot nor did she want any money given for Akot’s upkeep.  The new wife refers to Akot as a useless disabled child who is going to die anyway.  So, there is nobody to help the aunt care for the child and while the aunt knows it is a big risk, she must leave Akot at home so she can go work for food. When she has tried to bring the child to the garden, Akot cries and the work does not get finished; sometimes aunty is simply too weak to carry her.  The aunt tries the best she can under difficult circumstances.  If she has food, she leaves it for Akot instructing the neighbour’s children to feed her while she is away, but sometimes these children just eat it themselves and Akot goes hungry.  Aunty has even returned to find that the other children have beaten Akot.  It is late when the feeding ward admits Akot and we promise to return the next week to check on them and talk further.  Akot weighs 7.8 kg on admission- this is less than the 1st percentile of weight for her age.  July 31, 2009: Aunty tells us of how nobody from the family has come to see them since they were admitted so she is low on supplies and has no money.  She talks of how she thought of abandoning Akot, she was so sick herself and could not get treatment because the hospital charges to treat adults, but …she did not. Akot is improving in the feeding centre; they treated her for severe malaria again and the diarrhoea stopped a few days ago. She is still very lethargic and silent but aunty reports that she does play, bum scoots and is quite a talker when she is healthy. We conduct and audio record a formal interview with 169 aunty. They agree to be followed as a case study.  August 14, 2009: We arrive at the hospital but find that Akot was discharged a few days ago.  She stayed in hospital for 17 days and was discharged weighing 10.7kg (just above the 3rd percentile).  August 28, 2009: When we see her next in home in the camp, Akot scoots over to us smiling and we laugh to see her head is covered in mud- she had been playing “cooking” with other children and smeared her head and face in the process. Akot’s health has been much better since returning home and aunty reports that she is being welcomed more at the stepmother’s house now.  When father is around the stepmother treats her well, but when he is not…. Dad does not seem to feel any deep responsibility for the child.  Akot can stand now and will side step (cruise) if encouraged but she favours her left side for most activities.  Her father has been getting her to stand.  She has been associating more with other children and her speech is becoming more intelligible.  She is willing to play reciprocal games with us today, giving me her toy and then pulling it away and laughing. Akot chats and laughs and squeals with her aunty; they play with a straw and blow on each other….  They come together forehead to forehead….they are very attached to each other.  Dad arrives, he says they are going back to the village next year but the aunt and Akot will not be going with him.  Akot will stay with aunty because she is now her mother, and they will have to go back to the aunt’s marital village (traditionally a married woman goes to her husbands land). However, on her husbands land there are land wrangles.  When war ended the aunty tried to return to her former home but the eldest brother in law came and stopped her and a fight broke out. Her brother in law proceeded to build his own hut where hers used to stand.  She still says she will try again to return but needs someone to build them a hut (a traditionally male role).  Her younger son grew up in the camp so did not learn the skills to build a hut. The elder boy has epilepsy and while he can bake bricks he can’t get up to do the roof.  If returning to their former village does not work out, she will beg for a place to stay in the camp. But really, they are without any solid options for re-location.  Aunty is harvesting what crops were not destroyed by the drought and in the corner of the home are 5 bags of peas; this is what they eat, plain, when there is nothing else. We ask to 170 weigh Akot and find she weighs only 9.2 kg today- she has lost 1.5kg in the two weeks since discharge. We tell aunty the weight and she is concerned- she says Akot had diarrhoea two times last night and didn’t eat today. She says she will take her to the hospital for follow up on Monday.  September 2, 2009:  Akot is not home, they were re-admitted to hospital when they returned for follow up last week.  September 17, 2009: We find Akot lying on a papyrus mat next to an old lady but she looks miserable and frail.  She has lost weight and looks undernourished.  I greet the old woman and ask for the whereabouts of aunty and she tells me she has gone to the market to sell silver fish… I squat down and send my hand to greet Akot.  She looks at me inquisitively.  I smile and she recognizes me and smiles back putting her hand forward for greeting.  I then tell her that I am following her mother to the market and she just nods her head. The old lady reports that she is coughing a lot….  I look for aunty in the market and find her selling silver fish and groundnuts.   She tells me that I am lucky to find her around because this past week she has been going to the garden with Akot who has been very sick and has had no appetite ever since she was discharged from hospital. She vomits everything she eats, even water.  She says she realized later that Akot had tonsillitis and she took her to a local herbalist who cut (incised) the swollen tonsils and pus and blood came out (a common local practice for treatment).   But still, Akot’s appetite did not improve.  She no longer vomits but does not want to eat.  She does not want to eat the plumpy nuts (food supplement) given by the health centre.  Aunty and I return home and find Akot lying down but her body is very hot.  I have a cake with me that I give to her, but she just looks at it.  Aunty breaks a piece and puts it in her mouth and she begins to cough seriously and behave like she is about to vomit it out. Eventually she swallows and refuses to eat the remaining cake. I advise aunty to take her to the local health centre and she tells me they have run out of drugs, and the whole of this week parents were told to buy drugs from drug shops.  I ask her about bringing her to the referral hospital, she tells me she has no money and suffered the last time she was in the hospital, so she does not to risk going back without money.  We help her with some money for their stay and they go.  We learn later that she had to be blood transfused.  171 (While gone, their rice yields and they almost lose it to rot because they are not there to harvest- they manage to salvage it with intense work upon their return).  October 16, November 23, December 3, 2009, January 12, February 22 2010: Throughout these next 6 visits we continue to see the cycle of illness.  Akot is ok through October and November and when healthy she seeks out other children to play with and learns new skills like a full and rich vocabulary, to squat for pee and poo, pushing herself onto her hands and feet and even walking if someone holds her hands. Akot and her aunty have been looking at a picture book we left on a previous visit and they practice naming things.  Nonetheless, the December, January and February visits find her ill with fever, malaria, and diarrhea.  This barrage of illness is affecting her health, development and well being. She is not readmitted but is treated at home with anti-malarials and panadol.  We are told that in late November the aunt got into a physical fight with Akot’s step mother who accused the aunt of speaking badly of her and hating her because of how she treats Akot - a ‘useless disabled child who will die anyway’.  The aunt threatened to beat the stepmother if anything hurt Akot.  The case went to local court where the courts sided with the aunt and the stepmother was told to cease the statements she was making about Akot and value the child.  Afterwards, the stepmother absconded to her relatives, stealing the husband’s property upon her departure.  She was reported to the courts again but the outcome was as of yet uncertain.  In late 2010 with aunty’s permission we referred Akot to a local mission that provides day care for children with disabilities. Given aunty’s workload and Akot’s frequent health issues, it takes a few months for aunty to get organized.  During this period the problems of childcare continue with Akot experiencing more beatings, hunger and maltreatment by other children when left alone.  On the December visit we find her sick and alone between two buildings- she has bruising on her face from the aunt’s grandchildren.  March 2, 2010: Akot begins to attend the day care.  We check in on her there later in March and see her playing with an older woman, smiling, laughing.  Akot seems to be very fond of her teacher and is kept busy doing exercise and playing during the days.  The care issues are solved, but the health issues continue…  172 April 30, 2010:  The last time we see them at the end of the fieldwork, Aunty tells us of how Akot nearly died in the referral hospital on April 6 of malaria and severe anaemia.  She thought the child had actually died and was planning to put her body on her back and take her back to the village for burial when in the aunty’s own words: … she was dead.  She was put on oxygen, drip and blood, all of them at the same time on her body.  All of those things were making noise around her.  I sat on the chair as she was on the bed.  On a single bed there were four children at least and all of them were connected to machines that made noise in the head and I was busy watching all this.  As the machine made noise over Akot, I saw the tongue that she had bitten a moment ago and the foam that had come into her mouth, that she died with, I saw her spitting out this foam ‘tuk, tuk, tuk, tuk’. Then, she began to open her mouth; she began to open her mouth slowly as I kept watching.  Then I saw her begin to breathe and I told the doctor, ‘please doctor, look at how she is breathing’ he came and stood quietly and then left.  From there, I was watching her mouth that she had bitten, and now it was opening. Then by around 10, going on to 11 in the night, she started kicking her feet and she did not want the oxygen anymore, she wanted to run away, she had become conscious.  She had realized that she was on oxygen and she became conscious.  I started calling her name “Akot, Akot” and then she responded and so she was alive.  Follow up: When Stella checks in on them in later months we find them still living in the camp.  Akot is attending day care.  Aunty reports the cycle of illness continues. 


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