Programme on Substance Abuse
July 1993 (WHO/PSA/93.7)

A One-Way Street?
Report on Phase I of the Street Children Project
Part 7 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.

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In some cases there was evidence of certain moral, cultural or religious values and positions entering the process of the focus groups. It is not clear from the reports whether these were attempts to provoke discussion, or to "educate". This issue requires attention.

Although some girls were involved in focus groups in different centres, they were in general under-represented in the process. For those groups where girls were present, boys often dominated the discussions. It appears that little attention was paid to gender issues in the discussions. In some centres it was extremely difficult to access any street girls. For example, although it was possible to work in male juvenile detention centres in Alexandria and Cairo, it was not possible for females to work in such centres. It will be necessary to specifically address this issue in the next phase of the project.

It appears that, overall, the use of the focus group methodology was highly successful. It was a practical mechanism for consultation, provided much new and highly relevant information, and allowed street children to have a voice and be seen to be taken seriously. However, the lists of prompt questions need to be reduced.


In a number of settings, primary health care was provided as part of the participating organizations range of services. In others, links had already been formed with health facilities, and in some, new connections were formed. The mere existence of services or links to them does not imply, however, that they are accessible to street children who use drugs or that they have the expertise and/or willingness to provide such services.

Recognizing the brief history of the project, it is not clear from the reports that there was a development of "innovative and appropriate mechanisms" or an enhanced capacity of existing services and facilities to provide for the needs of street children who use drugs. It is not so much that they "need" specific techniques, as the health consequences of drug use are widely recognized and, in most cases treatable. It is more a willingness to receive these children as clients, treat them with nonjudgemental respect and without discrimination, and develop better mechanisms of access via community health nurses and physicians, mobile and extended hours services, locating health services in non-health venues, and the use of appropriate, safe and user-friendly buildings and facilities.

Most centres were still in the process of preparing strategic plans and considering appropriate responses. Some centres used street children themselves and other youths for the assessment process (India and Egypt). Specific centres where street children congregate were targeted, for example, train stations (Bombay), market places (Tegucigalpa) and juvenile detention centres (Egypt). In targeting these locations, the local community and authorities were consulted and encouraged to participate in the process. As a result of the project specific new activities and strategies were implemented. For example, railway station children in Bombay built a shed where they could attend informal lessons and they established a support group; in Egypt, Caritas was considering establishing a specific street children programme; a brick-making enterprise was established in Lusaka; training materials for street educators were prepared in Tegucigalpa; and a young people's street theatre group has incorporated the theme of drug use and AIDS in their drama in Manila.

Most centres decided to continue with focus groups for the purposes of assessment and monitoring and as a therapeutic intervention.


In addition to the above, other obstacles to better meeting the needs of street children who use drugs emerged.

These included:

    - corruption
    - entrenched drug cultures supporting communities, where some thought they would be worse off if the drugs industry were removed
    - how to keep the community involved and contributing, informed without boring and overwhelming them, and ensuring that they have a useful role
    - the expectation of some potential community advisory committee members that they be paid or offered some other incentive
    - the isolation and marginalization of services and workers, even within their own organizations
    - staff working part-time on the project who already have full time work commitments
    - finding "real" and acceptable alternatives to drugs and the streets
    - the absence of fathers in many cases
    - media influence promoting drug use
    - burn out of staff
    - the mobility of much of the target population
    - the existence of services which require ongoing attendance by street children who can be rather unreliable
    - the mix of different "tribes" and languages in some cities with little preparedness to integrate at any level
    - the understandable tendency of some of the population to be preoccupied with getting enough for themselves, rather than seeing cooperation as desirable
    - promises by the powerful not followed through
    - being unable to establish outreach services where their existence contravenes the law
    - the infiltration or surveillance of some agencies by the "authorities"
    - suspicion of research and outreach work by organization staff, who may wonder if there is a "hidden agenda"
    - competition for funding and other resources between agencies
    - suspicion and fear regarding staff and client safety, when "outsiders" become interested or involved
    - a lack of confidence and fear in having to deal with drug issues; and
    - misinformation about drugs and also street children.

There may not be much that can be done about many of these obstacles, but clearly recognizing them may assist in developing realistic intervention strategies.


It is highly probable that some of the street children interviewed played to the audience and exaggerated their drug use and predicaments. It is also highly probable that much of the information gathered is a true and reliable account. Swadi, making recommendations to improve the validity of adolescent 'substance misuse surveys' recommended that: "The key to reducing intentional error lies in increasing the respondents' trust in the procedure and the people behind it" (p. 481). In the Street Children Project, information was gathered in the main from known workers from agencies chosen for their demonstrated capacity to engage and work with marginalized and difficult to engage street children. To achieve this requires a large degree of trust.

While taking into account the cautions regarding data collected from street children in the manner it was for Phase I of the Project, it must be stressed again that it was not the intention of this Phase I to gather totally valid data from a carefully chosen sample. The intention was to gain some information, via a recommended process, which could add to that already present in the participating agencies and to give a broad overview of the lives of the children sampled to the rest of the world.


In order to illustrate some of the specific issues relating to street girls, a few examples taken from site visits conducted for this project follow:

The phenomenon of "street families" is spreading throughout the world. Children are being born on the street to adolescent street girls, creating second and even third generation street children. In the Mabini district of Manila, a 16 year old girl with her three month old baby and 18 year old boyfriend were found sleeping out in a park. Not far away, an adolescent mother stood in the distance while her four year old son sat outside a nightclub begging from pedestrians while nursing his baby sister. The mother was dependent on her children to earn an income and feared that a welfare agency would remove them from her custody.

In Mexico City, a family camped on the median strip of one of the major roads. While the young father juggled and danced at the traffic lights, the young mother, with baby in her arms approached motorists asking for money. Elsewhere, in the city, a middle-aged mother sat in the shade of a square, sending her two young daughters out to pull on the shirts and trousers of passing tourists asking for money. It was considered that the younger and dirtier the girls were, the more successful they would be in their begging endeavour.

In a "group home" for street children in Rio de Janeiro, a 14 year old girl had just given birth to a baby a month before. She was planning to remain in the home and raise the baby herself. Her pregnancy was a main factor influencing her decision to seek permanent shelter off the streets. In the same home street children ranged from the age of 4 to 18 years, both boys and girls. It was acknowledged that the residents were sexually active and information on safer sex, including condom use, was provided.

At the Second International Conference on Street Youth in Rio de Janeiro in September 1992, a panel of six street girls described how they had been severely beaten and their lives threatened by the police. They further described how they had regularly been sexually abused. One of the beaten girls was pregnant.

In Alexandria and Cairo, volunteer youth are working in juvenile detention centres providing recreational and educational activities for the detainees. It has been much easier for the volunteers to gain access to institutions for boys than those institutions specifically for girls. In addition, it has been very difficult for female volunteers to work in the male institutions.

In a compound on the outskirts of Lusaka, young girls, many pre-pubescent, sat outside the taverns late at night selling eggs, sugar, milk, nuts and other small goods. Reports indicate that it is not uncommon for intoxicated men from the tavern to sexually harass and even assault these girls.

A NGO residential institution for street girls was visited in Manila. Many of the residents were under the age of 10 years. Most had been involved in the commercial sex industry. Some described how that having sex was the only time they felt wanted and loved.

In Bombay, informal education classes were held for "slum" children. Whereas most of the boys were extroverted and actively participated, a small group of girls sat quietly at the back appearing withdrawn and depressed.

In Rio de Janeiro and Manila street boys reported that they often had sex with street girls after inhaling solvents.

In Sydney, within a period of five months, four adolescent girls died from overdose of a combination of heroin and benzodiazepines. They had been living on the streets.

These brief vignettes provide some content within which the broad spectrum of gender issues may be considered. Although they are only examples, they may help to orientate further discussions on how the specific issues of street girls may be addressed.


"Because of the PSA project we increased our role in substance abuse related advocacy activities, strengthened out relationships with the service providers, and introduced the valuable instrument of the modified social stress model and developed our experience with the use of the focus group methodology. It is possible that the service provider focus group will continue to meet and serve as a core group for the equivalent of a community advisory committee specifically organized around the substance abuse issue." (Honduras)

The cities within which the street children project was implemented vary considerably; size, population, mix of cultures and religions, types and effectiveness of pre-existing services, preparedness for cooperation, and stability of order. Within these cities, very different populations of street children were targeted, including detained youth, "slum" children, market children, station children, orphanage children and school children. Despite this diversity, the methodology and its documentation, with minor revisions, was regarded as sound and useful, and led to new information becoming available, some empowerment, more cooperation and an increased emphasis in existing organizations on the needs of street children who use drugs.

The methodology had been taken up by other organizations, for example Commonwealth Youth Programme in Lusaka, and an NGO, Le Programme de Portage in Montreal and Toronto. In the Bolivian city of Cochabamba and in Jullunder, Punjab State, India plans are under way to implement the project. There was an enthusiastic expectation of the next phase of the project, and PSA was seen to have validated workers and street children, and brought increased attention to their plight.

There appears to have been little duplication of service delivery, as reports from the participating organizations indicated this: "little duplication of services" (Rio de Janeiro and Manila), "no systematic approach to drug use by the NGOs" (Manila).

The findings outlined in the preceding sections indicate that there is widespread drug use by street children in the cities where the project methodology was implemented. This, in most cases, confirms the views of the participating organizations when they presented overviews of their respective situations in Geneva in February 1992. These drugs were mainly cheap and easy to obtain substances, often used in local industry (for example, glue used in shoemaking), and included alcohol, tobacco, cannabis, and significantly the inhalation of solvents. The street children focus groups did in some countries, however, give new information to street educators about the extent of use, and about new substances, or mixtures of substances that were the "fashion" of the moment. The street children indicated that drugs tended to permeate many of their lives, and that some local communities even depended for money, food and safety on the drug industry.

The links between being intoxicated and sexual behaviour need further attention to reduce increased possibility of unprotected sex and resultant pregnancies; sexually transmitted diseases, particularly HIV; exploitation; and violence.

Given the variable literacy levels, resources developed need to focus more on such materials and technology as: age and culture appropriate video-type materials, low-literacy level comics, street theatre, locally prepared materials produced in consultation with street children. In addition, it needs to be recognized that "resources" include repertoires of skills; all attention should not go to the development of material resources.

The actual involvement of street children in all aspects of the methodology warrants further attention. Consultation has begun, but real empowerment and community development will only be achieved by their active involvement in all processes. It is recognized that this will need to take into account what is acceptable in terms of local culture and religion(s).

Some consideration might be given to examining more closely the pathways to and from the streets, and to see if these have any impact on risk for drug use and other problems. For example, are there differences between those who were abandoned and those who chose to leave home, as Aptekar (1989) would suggest? Also important is how certain variables associated with separating from the family and/or the past impact on coping and survival on the streets. For example, age, circumstances which led to coming to the streets, and developmental stage.

Strategies for reaching out further to engage the less easily accessed street children, who may be more marginalized, suspicious, criminal, and/or more likely to be using more drugs, need to be considered. Some of these strategies may need to include the infiltration of street gangs of older children, and identification and engagement of key youths. Particular attention needs to be paid to the plight of street girls, how better to access them and to identify their specific needs.

Focus groups are but one means of rapid assessment. Others include key informant studies; for example, by turning the focus group questions into a semi-structured interview, as happened in part in Bombay. Phase II of the project may consider including more such rapid assessment procedures.

Likewise, more strategies may need to be developed to further strengthen existing families, so that their children may wish to return to them or spend more time with them rather than on the streets. The identification of a greater number of potential host/foster families will also be necessary.

The issue of mental health may also warrant increased attention. In some cities, high rates of suicidal ideation and attempts by street children were reported (for example, 55% Rio and 21% Cairo/Alexandria), and other indications of depression, anxiety and post-traumatic stress disorder evident. It is not clear from the reports whether any of the children met the criteria for mental disorder. Nor was it expected that the organizations should so report; this may be beyond their current capabilities. However, in developed countries increased attention has been given to "dual diagnosis", where a mental disorder coexists with drug use/dependency; be it causative, exacerbatory, or merely coexistent. Additionally, increasing levels of mental disorders among "homeless" people have been noted. It may be considered appropriate to give some attention to this in the next phase of the Street Children Project, recognizing that numbers of those with dual diagnoses may not be very large. If not attended to, an underlying mental disorder will frustrate attempts to stabilize the life of someone who is using drugs, as will not attending to other aspects of living such as food and shelter.

Written policies relating to the above issues are needed to address these issues in a manner the organization deems appropriate. They can provide a foundation for confident staff action in support of the organization's intents and purposes.


The United Nations Convention on the Rights of the Child states that:

    - Every child has the inherent right to life, and States shall ensure, to the maximum, child survival and development.
    - States shall ensure that each child enjoys full rights without discrimination or distinctions of any kind.
    - States shall protect children from physical or mental harm and neglect, including sexual abuse or exploitation.
    - The child is entitled to the highest attainable standard of health.
    - Children shall have time to rest and play.
    - States shall protect the child from economic exploitation and work that may interfere with education or be harmful to health and well-being.
    - States shall protect children from the illegal use of drugs and involvement in drug production or trafficking.

The reports from the organizations participating in Phase I of the Street Children Project indicate that these rights are not being met adequately, and in many cases denied or even blatantly breached. There are allegations of widespread marginalization of and discrimination against street children, exploitation, lack of coordination of existing services and few services prepared to work with drug using street children. The reports may or may not reflect national trends, but what they contain is of concern.

It is apparent that drug use among the over 550 street children, from whom information was obtained in groups or individually, is widespread and increasing. In developing countries, this use is of readily available drugs by young children. The older street children were more likely to use a greater variety of drugs, and to inject. This apparent progression is of concern. Changing international drug distribution routes, rural-urban and intra-urban migration, natural disasters, warfare, abandonment of children by parents and parental death, particularly from AIDS in Africa, are all impacting on this group and intensifying their difficulties. It was clear in some areas that drugs, their use, distribution and sale, had permeated communities.

Most of the street children involved in the project did not like their lives that much, but unlike many older injecting drug using youth in developed countries, they appeared cheerful and even optimistic in the face of their adversities. They were also much younger on average than street children in developed countries. Mostly male, they appeared to prefer to work, albeit in marginalized employment, rather than steal, fight and use drugs. They also wanted a relevant education. When they used drugs they used accessible and cheap substances, such as solvents, alcohol, tobacco and cannabis. Grouping together appeared to meet their basic physical and emotional needs which were not being met else- where. Their daily lives could be seen, in Felsman's (1989) terms, as a form of "urban hunting and gathering".

Although it has been reported that many street children band together and support each other, some centres, including Brazil report that many of their street children are isolated and "loners".

Street children do not need to be "pathologized" and treated paternalistically. Many of them demonstrate remarkable resiliency, and the stories and strategies used by the more resilient may assist the more vulnerable.

They also need alternatives to drugs to assist them to cope and dream. Assistance should be integrated and broad-based, as their difficulties are interconnected: for example, health, education, accommodation, employment, drugs, crime, disintegrating families, discrimination, violence, and so on. It appears that the focus of the street children project on drug use may have increased opportunities for the enhancement of integrated approaches.

Their health has been affected by the lives they have, in the main, been forced to lead. Increasing drug use can further add to their existing health problems of skin and other infections, respiratory disorders, parasitic infections and nutritional deficiencies by further lowering their immunity.

The participating organizations have indicated that they have been energized and feel validated by the interest of WHO via the Street Children Project of PSA. They felt that the plight of the children they are attempting to serve is being recognized internationally and taken seriously. They look forward to continued support and an expansion of the project.

They found the methodology useful in conceptualizing and contextualizing their work, and via it learned more about the lives and difficulties of street children who use drugs. They now, where possible, need to involve street children more in planning and implementation of interventions, not merely as a source of information.

There has been increased interest in and activity related to the problems of street children who use drugs in the countries from which the participating organizations come. For example, other organizations have joined the project and adopted the methodology, still others have expressed interest in doing so, and some proposed street educator training workshops plan to be implemented at a national level. Local workshops have been undertaken by each centre to disseminate information from and on the experience gained from implementing the project.

The Street Children Project is based on sound principles of community development and empowerment, and Phase 11 proposes to increase the participation of local communities, local, state and national organizations and services, street children themselves, and, where they exist and are capable, their families. It is hoped that the process will empower street children to be involved in the management of their own problems.

The Street Children Project has successfully delivered a methodology that, with minor refinements, provides a useful tool to gather relevant data, shape service plans and the implementation of strategies.


--For PSA consideration--

1. It is recommended that a second meeting be held in workshop format, for all participating centres, invited experts and other interested international organizations. This meeting might ensure that senior front-line implementors be involved, and focus on refining the methodology, develop training materials and guidelines and set objectives for further phases of the project. At this meeting: a) each organization would present its project, its findings, what it has learned, what it prizes, its plans, and perceived obstacles, b) PSA would work with the organizations to refine the methodology and develop materials and guidelines for the training of street educators, and c) the implementation process for Phase II would be developed and agreed upon.

2. It is recommended that the project implementation and evaluation be supported at the field level through site visits by a PSA Consultant. The visits during Phase I were found to be extremely valuable, and even crucial to the successful implementation of the project.

3. It is recommended that a mechanism be established whereby street children will be able to participate in the overall PSA evaluation of further phases of the project. Street children should be invited to critically review the project in order to reach empowerment goals.

4. It is recommended that closer relationships develop with other WHO programmes such as the Global programme on AIDS, Adolescent Health, Maternal and Child Health and Family Planning, Health Education, and the Division of Mental Health so that interventions are maximized and holistic, and that duplication of interventions is minimized.

5. It is recommended that a closer relationship develop with other relevant United Nations instrumentalities, in particular UNICEF.

6. It is recommended that efforts be made to identify international organizations which currently act as clearinghouses for information on street children and drug use, and on interventions and strategies found to be useful. Where possible existing activities should be coordinated. It would be helpful if a regular information publication could be produced, which would include abstracts of recent published literature, with an emphasis on information from developing countries. It would also be helpful if the publication was produced in a number of key languages. It might include contributions by street children and street educators, information on resources and interesting projects and interventions, in addition to more formal academic material.

7. It is recommended that PSA widely disseminate this report of the first phase of the Street Children Project using such international networks as UN and nongovernmental organizations, and to use the findings of this project to advocate for a more active international response to the problem.

--For participating organization consideration-administrative--

8. It is recommended that participating organizations specifically address the issue of the sustainability of their programmes. As part of developing the infrastructure for their programmes, local fund raising should not be ignored, and self-sufficiency should be aimed for. The pilot projects in each country have been with minimal external funding and some internal funding. However, for it to move beyond the pilot, ongoing commitment and funding will be essential. PSA may be able to assist in this, but only with limited financial support. Its role will be more of that of coordinating, evaluating, supporting, advocating and consulting. Part of the community development approach is to generate self-sustaining programmes. Obstacles to achieving such an aim need to be recognized. The second phase of the PSA project should be developed to include practical strategies which may be implemented by local organizations in order to ensure the sustainability of their programmes.

9. It is recommended that participating organizations ensure that Community Advisory Committees are representative of the community so that empowerment and community development become realities. To achieve this, some might need to split into two: 1) an advisory and support group which contains higher level government and civil functionaries who can advocate, attract funding and resources; and 2) one which oversights the development of the project more locally. The participating organization will have its own internal structures.

(TO PART 8 OF 9)

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