A One-Way Street?
Report on Phase I of the Street Children Project
Part 3 of 9
This report is reprinted in nine parts with permission of the World Health Organization, Programme on Substance Abuse, 1993. The document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated in part or in whole, but not for sale nor for use in conjunction with commercial purposes.
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responsibility of those authors.
WORLD HEALTH ORGANIZATION
PROGRAMME ON SUBSTANCE ABUSE
CH-1211 Geneva 27
Switzerland
Tel 791. 21.11
Youth homelessness and street children are phenomena, not only of developing countries, but experienced worldwide. Definitions of "street children", "homelessness" and "youth" vary across countries and cultures, as do the causes of homelessness and the associated problems. There are major difficulties in trying to estimate the number of street children and the magnitude of difficulties they experience as these populations are not adequately covered by national census, educational and health data. Depending on the definition used, estimates of the numbers of street children range from 10 to 100 million, the majority being located in major urban areas of developing countries. By regions, estimates have included about 40 million in Latin America, 25-30 million in Asia, and over 10 million in Africa. Boys predominate (71-97%), but girls often have more difficulties. For the purposes of the Street Children Project, the 1990 estimate by UNICEF of 100 million has been accepted, representing those with current difficulties, and those at risk.
Some of these children are "on the street", that is they maintain quite good family contact, often returning home each night. They may be on the streets to work, have fun, to pass time, or due to overcrowding in their homes which may provide little more than a place to sleep. In some countries, these are the majority of street children. Others are "of the street", where the street is their home. Some search for their identity on the streets.
The existence of street children is not something new. Historically, the streets of large urban areas have been both theatre and battleground for the children of the poor. They have been referred to in literature (e.g. in Medieval writings from Spain and Italy, and more recently Twain, Dickens, Gorki and Hugo) and have led to the development of organizations to assist them (e.g. the Salesian Congregation).
Their lives have tended to be romanticized by some, but in most instances they have been referred to in derogatory terms: "gamin" (urchin) and "chinches" (bed bugs) in Colombia, "marginais" (criminals/marginals) in Rio, "pajaro frutero" (fruit birds) in Peru, "polillas" (moths) in Bolivia, "resistoleros" (little rebels) in Honduras, "scugnizzi" (spinning tops) in Naples, "Bui Doi" (dust children) in Vietnam, "saligoman" (nasty kids) in Rwanda, or "poussins" (chicks), "moustiques" (mosquitos) in Cameroon and "balados" (wanderers) in Zaire and Congo. While their lives have been of genuine concern to some, it is more likely that they have been exploited and marginalized; used as cheap and expendable labour, for sex and for criminal acts.
Most accounts focus on particular groups at a particular time and tend to ignore the historical continuity which exists: most are male, their peer relationships, group life and survival strategies have been much the same whatever the time or place, and they are usually younger in developing than in developed countries. However, more recent economic situations (e.g. recession), political changes, civil unrest, increasing family disintegration, and natural disasters have led to larger numbers of children heading from rural areas and smaller towns to larger cities and their streets. Some are born on the streets to older street children, some come from families which can no longer support them due to overcrowding or poverty, some are members of whole families who live on the streets (street families) and others come to streets after being orphaned by armed conflicts, natural disasters, or parental death through diseases such as AIDS: one estimate suggests that there will be 16 million children orphaned by AIDS in Africa by the year 2015. The increased availability of a wide range of drugs adds to other potential health risks.
For the purposes of the Street Children Project, a number of distinct groups of young people have been subsumed under the definition of "Street Children":
a) Children living on the streets, whose immediate concerns are survival and shelter.
b) Children who are detached from their families and living in temporary shelters, such as abandoned houses and other buildings, hostels/refuges/shelters, or moving about between friends.
c) Children who remain in contact with their family, but because of poverty, overcrowding, or sexual or physical abuse within the family will spend some nights,or most days on the streets.
d) Children who are in institutional care, who have come from a situation of homelessness and are at risk of returning to a homeless existence.
While youth is generally a time of relatively good health, the nature of continuous exposure to the streets and the associated lifestyles makes street children vulnerable to a range of health and other problems which are not typically experienced by other young people. Factors which might contribute to vulnerability include:
a) Factors associated with the aetiology of their homelessness or street existence:
b) Factors associated with the physical conditions of homelessness and street life:
c) Factors associated with survival behaviours on the street and coping with stress:
d) Factors associated with inaccessibility to services and resources:
The particular health problems which have been identified among street children include:
o Malnutrition and other disorders of diet. Specific nutritional deficiencies resulting in such disorders as anaemia and endemic goitre.
o Infectious diseases, including:
o Oral health problems, such as dental caries and gingivitis.
o Hazardous, harmful, and dysfunctional drug use, including drug dependency.
o Unplanned pregnancies, often at a young age and with minimal, if any, ante-natal care; risks associated with practices for terminating pregnancies.
o Skeletal and soft tissue injuries from accidents and violence.
o Industrial and environmental poisoning.
o Non-specific symptoms such as headache, abdominal pains, lethargy and nausea.
o Psychiatric disorders:
o Cognitive disorders and learning difficulties.
While other children may have any or many of the above health problems, street life may increase prevalence, morbidity and mortality.
The use of drugs by street children, although functional in most circumstances, tends to add to their health and other difficulties. While drugs may be used by street children to keep awake for work, or alert to possible violence, to get to sleep, to anaesthetize physical or emotional pain, or to replace the need for food, they increase health risks and may lead to high levels of exploitation and violence.
The drugs used by street children are usually those which are most readily available and cheap. For example, glue in areas where shoemaking is common, solvents in industrial areas, coca paste and cocaine in coca producing regions, opium and heroin in opium producing regions, and almost universally various forms of inhalants, alcohol, nicotine, cannabis and pharmaceutical products. In developing countries, street children who use drugs do not usually fit the stereotype of the "addict" or "junkie" in more developed nations: anti-social and criminal, poly-using and injecting substances such as heroin and amphetamines. In contrast to more developed countries, street children who use drugs in developing countries often present as much more cheerful in spite of their difficulties, generous, resourceful, helpful to each other, friendly, and younger. Despite this, they tend not to inspire much compassion from the ruling and monied classes, but are usually further marginalized and discriminated against.
Some children voluntarily or under duress become involved with the manufacture, traffic, distribution and sale of drugs. For others, drug use may provide status within the street community. As mentioned above, the greater part of life in some areas revolves around the manufacture, distribution and use of drugs, with access to services and protection linked to compliance with drug traffickers.
Involvement in crime and drug trafficking bring rewards unavailable via compliance with mainstream societal values. For example, in Brazil a child joining the criminal/drug "profession" does so as one would learn most trades; in a highly organized and structured manner. First he, as they are usually males, would be used as an "olheiro" whose job it is to tell others that the police or rival groups are in the area (often by flying kites). The next stage is that of "aviazinho", a transporter of drugs, and thereafter to "indolador", who packs them, an "misturador", who mixes the drugs with other substances to increase the quantity, and finally to the rank of "solado", a "soldier" who sells the drugs.
Due to current Brazilian law, those under 18 years are treated fairly tolerantly. Thus they will be exploited by drug traffickers until age 18, when they risk being killed by members of the trafficking group ("queima de arquivo" - the burning of the archives or knowledge of the trade). In some slum communities (e.g. favelas) a child involved in this process will be respected, and even feared, thereby achieving a status that merely being a poor, street or market vendor does not. He brings in a reasonable wage, and his family may depend on this for survival, and even the provision of "luxuries" such as television sets and stereos. He may also bring protection. By such employment, he can maintain a link with his culture, which may be severed if he enters the "welfare" or "helping" system provided by the state (if available), in which he is labeled "an abandoned child" or a "transgressor" or "delinquent" and is placed away from home.
In addition, drug "bosses" may play a crucial role in providing a purpose, economy and welfare system to marginalized communities.
Traditionally, young people under-utilize existing health services. A number of factors contribute to this. Of significant importance is that the majority of health services have been developed by adults for adults. Many such services rarely recognize the unique issues of young people, particularly those of street children, and rarely try to accommodate for their often age-appropriate behaviours. Therefore, many young people view health services as unfriendly, threatening, mystifying, unhelpful and inappropriate.
Further to this, young people rarely identify that health is a major concern for them. This is more so when day to day survival is the paramount concern for many on the streets. In addition, young people often regard themselves as invulnerable, focus on the here and now, and do not concern themselves with the longer term consequences of their behaviour. If they are marginalized and believe that no one cares about them, the present is all they have. The presence of death squads and similar, in some cities, merely reinforces such beliefs.
For those who are unwell or concerned about their health, there may be a reluctance to seek help as it might make them different from their peers, or cause employers to look for someone in better health. There may also be no services available, or those that do exist may not provide appropriate services or are too expensive.
For those using drugs and involved in activities regarded by society as aberrant (for example, "survival sex"/prostitution), the situation is worse. This is despite the fact that adults are the main clients of street children engaged in sex work, and are usually in charge of drug manufacture, distribution and sale. Street children involved in such activities are often poorly understood by mainstream services. Agencies which do provide services for this population are themselves also often marginalized, regarded with suspicion, attacked, or barely tolerated by government, the population at large, or those involved in crime; whether the services are drug-related or not.
When "drug use" becomes a part of the presentation at a health service, there may be a tendency to refer the young person on to a specialist agency, if one exists. Where they do exist, specialist drug services tend to poorly understand issues pertinent to young people. Young people tend to be treated as mini-adults, and their particular needs get ignored. All of this helps to reinforce the mythical and "special" image held of drug use, and discourages health workers from developing skills to deal with the presenting problems. Denial becomes a major factor: denial by the adolescent that he or she has possible health problems, denial of a capacity by workers to respond, and denial by society at large of its role creating an environment which accentuates the difficulties of drug-using street children, and the part it can play in developing useful responses.
Given scarce resources, in developed as well as developing countries, street children, especially those who use drugs, do not usually receive high priority. Alternatively, the existence of street children may be viewed as a problem to be dealt with by the police and military, and street children are then "criminalized", placed in prison-like institutions or even killed. At other times, programmes which are regarded as effective in developed countries are replicated in developing ones. The results are usually less than useful, and can demonstrate cultural insensitivity.
It also must be recognized that, where street children are particularly marginalized and/or fear for their lives, they may not trust any services which exist. They may believe that the services are merely "fronts" for the police or welfare agencies, and that they will be captured. In fact, surveillance of services is not uncommon in some places. Alternatively, more senior drug or crime "bosses" may fear that children will tell the authorities about them, and so put overt or covert pressure on the children not to use services. The families of street children may hold the same views. The high level of mobility of many street children also makes it difficult to engage and maintain them in services, including treatment, welfare and other programmes.
Many health and welfare agencies, particularly governmental agencies, have fixed rules and admission criteria which exclude unaccompanied minors from receiving services. Some agencies will not see any unaccompanied youths under a certain age or anyone who does not have the necessary documentation for identification. For those agencies which are prepared to see such youths, it is common for specific treatments to be refused without parental or guardian consent.
Many street children are below the "age of consent", do not have parents or guardians, do not know a trusted adult who could accompany them for treatment, and do not have the necessary documentation. Although these obstacles relate particularly to the accessing of health services, similar problems exist for street children in trying to access housing, welfare benefits, educational opportunities and employment. After being turned away from different services on a number of occasions, and not having any adults to advocate on their behalf, these youths consider it pointless to try again, even when they are in great need.
Reports from a number of countries have revealed cases where street children have actually died on the streets after having been refused emergency treatment at local hospitals. Some NGOs working with street children provide a specific service in which they provide adults to escort children to services and assist them through the registration and processing phases. Some organizations have provided identification cards to street children in order to improve their access to services.
It has been recognized that many organizations, predominantly NGOs, work at the "coal face", developing nd implementing programmes for street children in developed and developing countries. Particularly in developing countries, these organizations have been working in very impoverished communities for many years, they have developed good networks among the street children and, in some cases won the respect, trust and support of their local communities. They have a good understanding of their communities, cultures and customs. However, they often lack an effective structure within which they can plan and deliver their services, particularly to street children who use drugs, and may lack a capacity to advocate for their street children at higher governmental levels.
The Street Children Project recognized the importance and work of these organizations, and believed that they were the most appropriate ones to implement any intervention strategy.
It has been described that a major problem working with street children is that of determining the reliability of the information that they provide. Lack of trust towards this population and disbelief in the "stories" that they tell significantly influence the accessibility to and quality of services provided. Service providers may feel uncomfortable with this lack of trust and, where possible, will try to avoid contact with street children. They may be cautious in treating these children, suspicious that they are exaggerating or lying about their ailments or other problems. They may feel resentful about being misled by some of the tales told, or they may dismiss what may be valid complaints as an attempt by the children to manipulate them.
Fabio Dallape states in his book about working with street children in Nairobi, Experience with Street Children: "children don't care to answer questions correctly. In fact, they rarely give correct answers to your questions whether you are a foreigner or a local. Whether you belong to their same tribe or not, they tell you what they think you want to know from them. They enjoy elaborating on the hardship of their life and how they must survive. They want to impress you, in fact they act like actors in the theatre".
Similarly, it is well recognized that there may be problems in obtaining reliable histories from substance users, particularly those who use illicit drugs. While many are critical of the validity of self-reports by adolescents, there is some evidence to suggest that self-reports may be more reliable and valid than believed. West and Farrington (1977) in their longitudinal study of London boys showed that the boy's accounts of their criminal convictions agreed well with official records. While stressing the need for caution in making too much of adolescent offending self-report studies, Rutter and Giller (1983) suggest that the data yielded can be very useful. In relation to adolescent drug use self-reports, Winters, Stinchfield, Henly and Schwartz (190-91) stated from their study of over 1500 adolescents "... that the great majority of drug clinic and school teenagers gave temporally consistent reports of substance involvement and that only a small proportion of drug clinic and school subjects presented extreme response bias tendencies." (pp. 1379-1380)
Those health and welfare workers or researchers gathering information need to be sensitive to the individual or group being interviewed. Although data collection methodologies require inbuilt validity checks, special consideration needs to be given to the interpretation of messages being given. The "reality" for street children (and for drug users) is very different to that of investigators, service providers and the immediate community. Their conceptualization of issues is determined by very different thought processes based on very different life experiences. For example, as part of this project, when one street boy in Rio de Janeiro was questioned about his understanding of religion, he replied that it was a place he could go to sleep and shelter from the rain. This demonstrates the importance of not rejecting their responses as being unreliable, but the need to explore further what they are trying to say. In relating the stories of their lives, they may be communicating in a way which is open to misunderstanding. "Why is it that they act like actors in the theatre?" We should investigate what gains there are to behaving in such a way.
The purpose of this phase of the project has been to determine the feasibility of utilizing the project methodology to assist agencies working with street children to improve strategies for the prevention, assessment and management of drug problems in this population. An additional benefit to this process has been the collection of data on street children through local situation assessments. The phase was not formulated to collect reliable and comparable data across different countries. With regard to the reliability of the specific data discussed, such a limitation of the project needs to be recognized. However, this exploratory phase has opened a window into the lives of street children, revealing information and issues which require further investigation and attention. The next phase should focus on the reliability of local information gathered from street children, its interpretation and in trying to gain some basic understanding of their communication and thought processes.
In general, males and females are not equally represented in populations of street children. In most, if not all, communities males overwhelmingly outnumber females. Although it is not clear as to why this is the case, there are a number of factors which may contribute to this phenomenon.
For many cultures and specific communities, the phenomenon of street children is new and is perceived to be a consequence of a rapidly developing economy and urbanization. Not only is it new, but it is often considered to be an embarrassment to and viewed as a failure of their respective societies. It appears that in these communities the least tolerated aspect of this problem is having to witness young girls on the street. Where communities feel a need to protect their children, often it is traditionally girls who are afforded the greatest protection, or who are placed in roles which keep them at a distance from the outside world. This community intolerance, which differs for street children according to gender, is a critical factor in determining how a community responds to the problem of street children. For example, many Islamic cultures do not tolerate girls living or working on the streets.
For children who work, including those who have families, it appears that boys are more likely to be involved in activities which put them on the streets, for example, street vending, running messages, providing street entertainment, washing cars, collecting scrap, pick-pocketing, shoeshining, riding trishaws, and involved in drug dealing. Whereas girls, often are employed or earn an income off the streets, for example working in factories, making crafts, employed in domestic services, involved in commercial sex and vending. It is also reported that often girls who work on the streets are under the supervision of an adult. For example, while her mother stays in the background, a young girl may sit on the roadside selling farm produce or small goods or may approach passing cars or pedestrians begging for money. These apparent differences may reflect cultural beliefs that males are stronger, more independent and are able to fend for themselves on the streets. Some cultures consider that it is the responsibility of the male child to be the provider for the family, thus forcing him out to earn an income.
For those children who have left their families, the gender differences are still evident. Physical, sexual and emotional abuse are common reason for children leaving home. As survival on the streets is less threatening for boys, it may be an easier decision for a boy to leave an abusive family setting than for a girl. And, if a girl does leave home, it may be more likely that she finds alternative accommodation with other family members or friends. Often girls who end up on the streets are recruited into the commercial sex industry or are taken into institutional care. It appears that this is less likely to happen for boys in similar circumstances.
The reasons why there is such a large gender difference with regard to the numbers of street children are obviously complex and multifaceted. The preceding discussion only alludes to some possible factors which require further investigation. In particular, any such inquiry needs to address specific cultural issues which determine the differences observed.
The differences between street boys and girls are not solely those of numbers and activities. Street girls are at a greater risk of experiencing certain health problems than boys. Girls are more vulnerable to sexual exploitation and both physical and sexual abuse. Girls also experience specific problems related to adolescent female development and reproductive health. On the streets, risks are considerable with unplanned pregnancies often complicated by minimal or no ante-natal care, poor nutrition and hygiene, violence, sexually transmitted diseases, no shelter, and the possible use of drugs. Some girls risk unsafe abortions outside of the health care system. Often girls who complete a pregnancy will have no support in their attempts to mother their babies. Apart from these specific, well-known reproductive health problems, attention needs to be given to other gender specific health issues as they relate to street children, including the use of psychoactive substances.
Another area which requires further attention is that of factors which influence access to health and welfare services according gender. In section 3.6 of this report a more detailed discussion on access to services was presented. In particular, the issue of discrimination against girls needs to be considered.