A One-Way Street?
Report on Phase I of the Street Children Project
Part 5 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.
The views expressed in documents by named authors are solely the
responsibility of those authors.
WORLD HEALTH ORGANIZATION
PROGRAMME ON SUBSTANCE ABUSE
CH-1211 Geneva 27
Tel 791. 21.11
5. EVALUATION OF THE STREET CHILDREN PROJECT
The views expressed in documents by named authors are solely the
responsibility of those authors.
WORLD HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION
Translation of the PSA documentation occurred where necessary. In some cases difficulties were experienced in translating concepts into those which were culturally understandable, but this was largely overcome. In other cases there were expenses involved which precluded translation of all materials or prevented a more rigorous translation/back translation process.
Briefings occurred for staff of participating organizations and others, including street educators chosen to be facilitators, and training provided where considered necessary. Participating organizations then began implementation of the methodology and documenting the process and findings. The project was implemented in Rio de Janeiro, Montreal and Toronto, Alexandria and Cairo, Tegucigalpa, Bombay, Mexico City, Manila and Lusaka.
Most local evaluation reports from the participating organizations, via their principal investigators, were provided promptly. This reflected a great deal of work and dedication, including many extra hours of unpaid work. The reports also reflected a tremendous enthusiasm and energy, particularly so when some cities were experiencing civil unrest and interruption to services at the time. They indicated that the involvement of WHO via PSA had contributed to this, and that many higher level government and nongovernmental authorities became involved, and were directly supportive or guaranteed support in the future.
In some countries, other NGOs indicated a desire to join the project, and did so with their own financial support. Likewise, Le Programme de Portage of Canada and the Commonwealth Youth Programme Africa Centre in Zambia joined the project, and new street children projects began in Bombay, Cairo, Alexandria, Lusaka, Montreal and Toronto, with one planned for Punjab State, India.
The site visits by the PSA Consultant were well received and valued, and through them a number of organizations who expressed an interest in or were working with street children were identified as suitable and/or expressed interest in joining the project. For example, Caritas Egypt is considering starting a specific programme for street children in its organization. Visits to a wider range of organizations and agencies by the site visitor led to recommendations for expansions of the project locally and the inclusion or targeting of various groups. For example, Grupo de Estudios en Desarrollo Integral (GEDI) in Mexico City, the Poor Children Programme of Caritas Egypt, children of the Manshet Naser area of Cairo, the "Follow-Up Care" unit and Juvenile Police Section of the Alexandria Police Department, and a range of Christian, Muslim, governmental and nongovernmental orphanages/residential homes from both Cairo and Alexandria. The site visitor also talked with a wide range of the street children involved in the projects in each centre, either individually or in groups.
Most participating organizations reported that the Community Advisory Committee meetings and focus groups provided for increased social interaction and cooperation. Their focus groups may have been significant in contributing to this.
The street children focus group process was modified for individual interview format where a group was seen as inappropriate. Both focus groups and interviews yielded rich information. Most participating organizations believed the information gained from the street children was reliable and truthful, with only few instances of distortion or influence. however, it was considered necessary to further investigate the reliability of information obtained and to identify opportunities for internal validity checks in the methodology.
There was a universal expression of interest in moving to further phases of the project, and in the sharing of information between participating organizations.
Some reports estimated the numbers of street children in their cities or countries. It must be recognized that these figures are estimates made by the participating organizations and may not reflect official estimates. For example, it was estimated that there were 7-8 million street children in Brazil; about 27,000 in Bombay; 3,000 with 10,000 at risk in Lusaka and 25,000-30,000 throughout Zambia; and 50-70,000 in Manila with about 1.2 million in the entire Philippines. The overwhelming majority were boys. Many of the children were "in the street" returning home at night, literacy levels varied, and most had not completed elementary school.
All participating organizations reported that the conceptual framework as presented in the Modified Social Stress Model was very useful, simple to understand and had wide application. It was considered that the integrated and holistic nature of the model provided a good structure for undertaking rapid situation assessments and planning appropriate responses. It was considered that the model could be used to address other risk behaviours, not only that of substance use. One way of examining the usefulness of the Modified Social Stress Model is by reviewing what information in relation to the six variables was elicited from the street children, service provider, and community advisory committee focus groups and/or interviews.
"The modified social stress model was found to be quite useful in organizing one's thinking as to the various variables involved and the necessity to consider them all and their relative importance when evaluating the relative risk of substance use in a population." (Report from Honduras)
The following provides an overview of the information gathered. Individual centre reports provide more details.
"I don't like to remember anymore what it was like living in the streets" (Filipino boy).
"Our dream is to be alright one day" (youth from Montreal).
The major life events which had occurred in the lives of the children included:
Some street children reported having been used by terrorist and criminal groups in subversive activities against tourists and others, and to participate in drug distribution networks.
Enduring life strains and everyday problems included:
Many of the street children were involved in work such as: shoeshining, carrying goods in markets, running errands, traffic light or street corner vending (some carrying trays with them, others set up tables outside taverns at night, or business houses during the day), clowning, playing music, piece work, cleaning cars, garland selling, helping their mothers sell rural produce. Others were involved in commercial or survival sex.
Much of the work involves risks and stress. For example: young girls selling eggs outside taverns where intoxicated adults leave and sexually exploit the girls; children standing in heavy traffic inhaling exhaust and other fumes and at risk of injury from vehicles; expectations of, or forced unsafe sexual practices by adults; having earnings taken by bigger or stronger persons and threats from criminal groups (including the illicit drug industry).
Many have dreams of a future. For example, to become pilots, teachers, police officers, doctors, nurses, lawyers, businessmen, farmers and tradespersons. It is interesting to note that most of these are caring, service areas of work, or law enforcement. Most wanted education and fairly traditional futures. When reality tested, dreams change. For example, one Filipino boy said that if he could not become the pilot of a plane, he could become the "pilot" of a jeepney.
For many the thought of leaving the streets behind induced fear: a move from something known, albeit difficult, to something poorly understood and which they felt they had little confidence in their ability to deal with.
Some workers from Montreal and Toronto described the life of street children as going in a cycle, and only some break from it: 1) The Honeymoon Period: characterized by freedom and excitement, with drugs becoming a part of this as experimentation. 2) A Coping Period: where basic day to day survival becomes the total preoccupation, with drugs being used to assist coping. 3) A Routine Period: where they come to view their lives as monotonous and in need of change, and drug use also becomes routine and non-fulfilling. It was reported that it is more difficult to reach street children during the honeymoon phase. Many seek assistance or only present to health services when they reach the last stage of the cycle. No other participating centres reported a similar or so well defined pattern. Care should be taken in not universalizing this concept to other cultures or centres, recognizing the complex and multi-faceted nature of the problem.
"After intake (of solvent) you feel an earthquake and that God is above you. Once, the half body of Rizal appeared as a 'manananggal' (a flying witch). After a few hours, you lose your appetite, feel very weak, tired and sleepy." (Filipino street boy)
In relation to reasons for drug use, most said they used because of peer pressure, to socialize, for confidence, to relieve hunger pains, to cope, to sleep, and to forget fear and sadness.
Most organizations reported that a significant proportion of the street children involved used drugs other than nicotine (e.g. about 39% Rio, 40% Manila, over 23% Mexico City, over 43% Cairo/Alexandria, and nearly 100% in Montreal and Toronto) and most reported that the street children said that drugs were a problem for their communities (e.g. 100% Manila, 91% Rio). It must be noted again that these figures, and all those to be quoted below, are estimates made on data collected by the participating organizations and may not reflect official views. Comparisons across centres is difficult as the ages of street children varied between centres. Some centres involved significant numbers of street children under the age of 10 years, whereas substance use is more likely to be a problem among older street children.
The centre reports outlined the drugs used by the street children in the various participating cities:
Brazil: Rio de Janeiro: the use of solvents, alcohol and tobacco predominated; the use of cannabis, cocaine and drug injecting was more likely to occur in the favelas.
Canada: Toronto and Montreal: most were poly-drug users and frequently injected.
Egypt: Cairo and Alexandria: tobacco, glue, solvents and cannabis (hashish) were the main drugs used. There was some use of cough syrups, benzodiazepines and barbiturates, with an increasing use of amphetamines. Drug injecting was indicated in an earlier country report, though there were few younger injectors. There was low alcohol use, mainly due to Muslim culture. 13% of children interviewed described their parents as being drug dependent.
Honduras: Tegucigalpa: glue, and to a lesser extent cannabis, alcohol, tobacco and depressants were the main drugs used. Older youths were more likely to be poly-drug users.
India: Bombay: tobacco ("beedies"), glue and solvents were the main substances used, with mixed pharmaceutical wastes from local laboratories, cannabis and home brew alcohol being used to a lesser extent. Older children may use heroin ("Brown Sugar") and methaqualone, but use was limited.
Mexico: Mexico City: inhalants, alcohol and cannabis were the main drugs used.
Philippines: Manila: use of solvents and glue ("Rugby") was common; cannabis, alcohol, tobacco, methamphetamine ("Shabu"), diazepam, cough syrup, "X-Pinoy" (benzodiazepines and Artane), "buri" (dried palm leaves) mixed with minted candies were used less often.
Zambia: Lusaka: cannabis ("dagga"), glue ("Bostik"), petrol, were the main substances used, in addition to alcohol ("Chibuku" [maize and malt + soy beans for thiamine], "Kachasu" [spirit from grains] and "Mosi" [a strong wine]). Few children used heroin (injected) and cocaine due to their cost, but some used methaqualone and diazepam.
Overall: Drug use was widespread. The young age of some samples was obviously correlated with less use, and use of fewer substances. Most saw drug availability and use as permeating their whole community.
Solvents are often the first drug that street children experiment with and learn drug using behaviours. As street children became older they were more likely to use a wider range of substances and possibly start injecting. The picture for Canada represents what is seen as typical of developed countries, poly-and injecting use of drugs such as heroin, cocaine and amphetamines, plus widespread use of pharmaceutical, tobacco, cannabis and alcohol. The developing countries may be beginning to follow this trend, especially as distribution routes change (e.g. increasing use of amphetamines in Egypt and heroin and cocaine in Zambia).
The drugs used provided powerful effects, through a combination of their pharmacological properties, the user's expectations and the context within which they were used. They were reported to relieve hunger pains, to help the children forget their fears, anxiety and sadness, to provide status and peer membership, and to aid in their dreaming. In some cases, the children would not use particular substances because the effects would last too long and/or interfere with their capacity to work. For example, in Bombay some street children would not use benzodiazopines because they made them too tired to work. Some street children in Rio de Janeiro avoided using alcohol because it made them feel vulnerable, not being able to protect themselves when intoxicated or asleep.
However, as street children in developing countries are often malnourished and may have chronic health problems (e.g. skin infections, respiratory disease, parasitic intestinal conditions), their immune systems may not be robust. The use of drugs can make this situation worse. A further complication is that they are usually not vaccinated.
The consequences of substance use reported varied. For example: over-dosage, convulsions, accidents where injuries were sustained, unsafe sex, and non-specific complaints such as headaches and stomach pain (both known to be related to the use of solvents). In most centres, violence between street children was reported while they were intoxicated using solvents. Also, Rio street children reported promiscuous sexual activity while using solvents.
It is also noted that there were frequent reports of police and drug enforcement officials being involved in the supply and sale of drugs to street children in some cities. In other cases it was alleged that health workers sold children drugs, such as diazepam.
"All the participants said they have lost someone close to them, either a friend, parent or relative. This makes them think of death sometimes and the unknown." (Report from Lusaka)
A large proportion of some of the groups still had strong attachments to their families. These may need strengthening, so that the streets take up less of their time. However, many of these attachments had been broken by death, abandonment, betrayal and exploitation, and rural-urban and intra-urban migration.
Others appeared very attached to street educators and house/group home parents and workers. One of the current difficulties, and one which could increase with expanded service provision, will be how to transfer these "artificially created attachments" to more "normal" community ones.
Likewise, are the very strong attachments to other street children. Some of these were very positive and protective, and involved caring and competent peers. Some involved "comfort sex". While this solidarity provided for safety, the meeting of emotional and material needs, unless those to whom street children attach are functioning well enough in the community, they may not provide strong, coping role models.
Some attachment to school and teachers was evident. By and large the children valued education, although it had not been extensively available to a large number of them for a variety of reasons. For many of those who attended school, limited community resources meant that they would spend only a few hours a day in formal schooling. Some relied on informal education through NGOs. It was usual for them to spend more time on the streets than in school.
Other attachments reported were negative ones, where children felt trapped in unsatisfying relationships to families wherein such events as physical, sexual and mental abuse was common. Likewise, there were similar negative attachments to employers and persons involved in the drug industry or other criminal activities.
"Taking to the streets is a way of searching for identity, earning a living out of it, and contributing to the family's income." (Report from CYP Africa Centre, Lusaka)
"Most children felt that with the positive support of the street educators, and other elders in the family/community coping with the present stressful situation would become less problematic." (Report from Bombay)
A variety of strategies for coping with street life emerged from the reports of the participating organizations. The main one was working. Street children are introduced to life on the streets and work by other street children. Often a newcomer might help a more established child by minding his or her table of small goods while the owner carries out other business. For this a small amount of the taking will be paid, and skills and coping strategies taught. Eventually the newcomer can set up his or her own business.
Some children reported that they allowed themselves to be caught and placed in a drug treatment facility, institution or group home. This brought some into contact with the help they wanted, but did not know how to get, or could not access. One 17 year old in Rio came for help so that he could avoid being killed. He felt he would be the next to die ("bola da vez"). This is not an infrequent occurrence apparently for those who have been involved in the illicit drug industry on turning 18 years of age and being more likely to be targeted by the police to tell what they know.
Other activities and strategies included:
Some of these strategies and skills are pro-social, while others demonstrate skills and strategies utilized within anti-social activities. However, the skills themselves and the planning capacities used in the anti-social activities may be transferable to pro-social ends, if such ends are perceived as valid and rewarding alternatives.
"Only a few street children utilize existing health care services because they tend to reject adult values and align themselves more with their peers, so that it is difficult for them to submit themselves to a health care system controlled by adults." (Report from Mexico)
The following became clear, from the reports as actual or potential resources. Some are qualities of the children which they bring with them to the streets or acquire there:
In a practical example of resources being developed, the Bombay project is considering providing street children with a sturdy rucksack and bed roll. The rucksack would contain soap, toothpaste and a brush, a towel and a change of clothes. It would be a place where they could keep their belongings. Living on the streets often precludes the collection of any belongings. Usually children will wear the same clothes until they can find some clean clothing that they can change into. As they have no place to store another set of clothes, often the children will just discard the dirty clothes that they had been wearing.
Other resources are qualities of those who care for and provide services to them. For example, some street educators/outreach workers were seen as an important resource. However, in developed countries such workers "burn out" very quickly. There were no comments on this in the reports, but it may become an issue.
Some participating organizations were running "drop-in" centres, street clinics and outreach programmes. Other organizations were planning to establish such centres and programmes. Services, agencies and resources which have a mandate, and should or could provide for their needs were often viewed very negatively. Most of the street children disclosed that they had been badly or disrespectfully treated, or discriminated against and rejected by health, educational and welfare services. This included denigration, violence and even sexual assaults. Access to services clearly remains an issue.
There was also a lack of adequate role models available to which positive attachments could form, along with a lack of host/foster families capable of taking in children willing to be placed. However, efforts at recruiting host families and "aunties" had begun, or were planned by a number of organizations.
Some children indicated that they did not "deserve" services. They appear to have accepted the negative attributions placed upon them by some members of society and/or their families.
Apart from substance use, other risk behaviours were described by street children. Most notably, they described high risk sexual practices. Reports indicated that 20% + of street children were intoxicated while having sex with opposite and same sex partners and clients (Manila, age range 8 to 19); 44% claiming having been forced to have sex, 81% not using condoms of the over 53% who reported being sexually active, 60% not knowing what safe sex is, 31% of the girls reporting having had a child and 19% having had an abortion (Rio, average age 13.9 years); and 79% of males reporting sexually transmitted diseases and 16% claiming to have at least one child (CYP, Lusaka).
It was clear that for many children their lives to date contained one, if not more, major life event. This often resulted in them moving to the streets. They could be described as "abandoned". For others, their lives to date appeared to have been endurance tests, with continuing stress and strain. Some of these children had made a decision to leave home as their attempt to change the situation; they could be described as "walkaways". In many cases, the children continued to live at home, but for financial reasons or for relief from unsatisfying domestic situations, they spent much of their days on the streets. In some cases their parents pushed them towards the streets to obtain work and, consequently to improve the family financially. These children formed a mixture of those with lower stress levels and strong, loving family attachments, and those with poorer attachments and growing levels of stress; the latter being very much a group at risk.
Most did not willingly involve themselves in lives of crime, but attempted to cope with their situations in various ways, including working and being in solidarity with other street children. Drugs were readily available, and their use in some communities even appeared "normal". Drugs also provided, through a mix of their pharmacology and the expectations of the user, a means of coping with life and having some fun.
Resources, other than themselves and their peers, were rather scarce. They had experienced discrimination, rejection and even brutality from those ostensibly there to assist. Some even felt that they were not worthy of services. Adequately coping role models were rarely available.
While none of the above is really "news" to those involved with the lives of street children, the use of the six variables of the Modified Social Stress Model to group data appears useful and provides a framework whereby information obtained may be used to develop appropriate strategies. It also clearly indicates that by addressing only one or two variables a strategy may not be effective, due to the impact of the variables not included.