Family disfunction, poverty and HIVAIDS among homeless street children

[Full title: Family disfunction, poverty and HIVAIDS among homeless street children: What can the family physicians offer?]

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Open Forum Family disfunction, poverty and HIV/AIDS among homeless street children: What can the family physicians offer? Olufemi, Olusola, MURP (Ibadan), Ph.D. (Wits) Associate Professor, School of Architecture and Planning, Faculty of Engineering and the Built Environment University of the Witwatersrand, Johannesburg Olufemi Ademola. MCFP (SA), M Fam Med, MB; BS, MBA Family Physician, Health Region A, Johannesburg. Correspondence: Prof. O Olufemi, Tel No: 011-7177718, Fax No: 011 4032519, E-mail: 041olo@cosmos.wits.ac.za. Keywords: Homeless street children, Family dysfunction, Poverty, HIV/AIDS, Comprehensive Care. Abstract This article aims to create awareness among the family physicians on street homelessness among children, in South Africa, more importantly its relationship to HIV/AIDS epidemics, family dysfunction, poverty and child abuse. Such awareness, apart from giving family physicians a better understanding of this important social issue in their environment/community, will also put them in a better position to intervene appropriately whenever they are in a situation to provide care to this group of children. (SA Fam Pract 2003;45(2):6-9) INTRODUCTION Lester Brown's' editorial article in the South African Family Practice December/January 2002 edition was a piece to provoke thoughts among family physicians and many other professionals. The article in a way questions how professionals from different fields including, family physicians, could collectively employ their skills and knowledge in solving the problems of HIV epidemics that is restructuring the African population. Lester Brown specifically hinted of the millions of potential orphans who might become street children by 2010. While raising awareness on the street child phenomenon that would become a serious problem within the next eight years, the fact is that street homelessness. among children is already rife in South Africa, probably not to the knowledge of most of us. Presently, in South Africa HIV/AIDS epidemics remains an important cause of street homelessness but it is equally important for family physicians to be aware that family dysfunction, child abuse and poverty 2.3.4 6 are also significant underlying causes of homelessness among children. Lester Brown raised some pertinent social issues, including homeless street children that Family Physicians need to take cognisance of. WHO ARE THE HOMELESS STREET CHILDREN? A street child' is "...any boy or girl... for whom the street (in the widest sense of the word, including unoccupied dwellings, wasteland etc) becomes his or her habitual abode and/or source of livelihood and who is inadequately protected, supervised, or directed by responsible adults". The street homeless people (street children inclusive)" are: "those who lack basic needs (safe water, sanitation); those who lack real homes; those living in bad housing; those sleeping on pavements. sidewalks or kerbs; those who lack personal needs (voice, expression, dignity, self-determination". In the Policy and Strategic Guidelines on street children in South Africa' a street child is defined as "a child under the age of 18 and who has left his/her home environment, part time or permanently and who spends most of his/her time unsupervised on the street as part of a subculture of children who live an unprotected communal life and who depend on themselves and on each other, not on an adult for the provision of their basic needs (children under the age of 16 years are regarded as street children, and above 16 years they are regarded as youth)". The United Nations Centre for Human Settlements" categorised street children into three broad groups as follows: ⚫ "Children at high risk are those who live in households that do not satisfy their basic human needs. They may spend time in the streets to work or *hang out and are exposed to street culture. It is this marginal group that is at most risk of becoming street children. Children in (or on) the streets are youngsters who spend a substantial portion of their time in the streets, usually as child workers but tend to maintain a strong family link. SA Fam Pract 2003;45(2)

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Open Forum Children of the streets tend to be few compared with the multitude seen working in the streets. These children have had their family ties severed through running away, abandonment, family disintegration or death of their parent(s). Many are abandoned or orphaned. They are socialized outside of the schools and the family with few conventional contacts with adults". Other special groups of street children that have been identified' are: "Children with disabilities, including children with severe mental and or physical disability. Refugee children, including lost and abandoned children, children of imprisoned mothers, and children living on the street. + Children living with HIV/AIDS. Any other categories of children who are deemed to be in especially difficult circumstances". Within the South African society, street and homeless people including children are labeled as malalpipe (those who sleep in the pipes); malunde (those who sleep away from home); skadukinders (shadow children) 1011121314 and sometimes strollers or children on the streets. Street homelessness and its health implications for Children Street Children, usually children under 18 years, spend a greater proportion of their time living and/or working on the streets. Many years of political violence, migratory labour, forced removals as well as rapid urbanisation resulting from the abolishment of influx control have severely impacted on the lives of and have forced many children into the streets. In addition to street homelessness, table 1 presents some of the general socio-economic circumstances of children in South Africa 17. The Draft Green Paper on Social Services and Population Development" states "there are many children working and living on the streets. Of these one third are 'children of the street' while the rest are "children on the street", that is children working but not living there. Only a small proportion of these children is formally orphans or homeless. Many of the children are functionally SA Fam Pract 2008;45(2) Table I: Key indicators of South African Children ⚫ Six out of every ten children live in poverty, mostly in the rural areas. 180000 children under 15 were estimated to have lost their mother or both parents to AIDS. An estimated 5% of children between the ages 10 and 16 are not in school. * 42% of children under 7 years of age live only with their mother and 20% do not live with either parent. • Child labour figures were estimated at 200000 between 10 and 14 years old. An unspecified number of children are subject to commercial sexual exploitation. In September 1999, there were 2026 children awaiting trial in South African prisons and 1375 serving sentences. homeless because of cruel and disinterested parents or stepparents, alcoholism and eviction". Schurink and Schurink affirmed that in South Africa 60% of the street children are children on the street who work as beggars and peddlers in contribution towards the financial support of their families while 40% are children of the street, who have little or no contact with their families. The National Programme of Action indicates there are over 10000 street children in South Africa. The White Paper on Welfare estimated there are approximately one million street children in South Africa. Olufemi22.23 estimated there are about 1107 homeless street children in Johannesburg inner city while the Gauteng Alliance for Street Children estimated there are about 600 homeless street children in the Tshwane Metropolitan area. Reasons commonly given by street children leaving home voluntarily include: neglect or abuse; feeling unloved; hunger; intellectual boredom; conflict with care-takers; a wish to ease financial strain in the household; bad schooling experience; family misunderstandings; or a combination of these factors24,25,26 Poverty and family dysfunction are important antecedents of street homelessness among children. These factors have resulted in a significant increase in the number of homeless street children, in South Africa, especially in the Johannesburg metropolitan area of Gauteng Province. It cannot be overemphasized that family physicians need to recognise and be sensitive to the mental and physical illnesses resulting from neglect, hunger, living conditions and abuse which characterise the lives of the homeless street children. Homelessness has significant negative impact on these children's health and they demand family physicians awareness and understanding of the problems involved for the children to receive appropriate and effective healthcare. It is critical to put family physicians in the perspective and enable them gain sufficient insight into the potential health problems threatening the survival of these children. Some specific and important contextual issues of child street homelessness for family physicians including poverty, family dysfunction, child abuse, HIV/AIDS and the orphaned are hereby highlighted. Poverty The State of the Nations Children's report identified poverty as the most important factor underlying the street child phenomenon. The report also indicated that about 6 out of every 10. children lives in poverty. In situations of extreme poverty, "child headed households find their way onto the streets where they become involved in commercial sex work, begging, stealing and doing menial tasks Forty five percent of the street children at the Johannesburg branch of the Street Wise (a street children NGO), 80% of those at the Soweto branch and 92% of those at the Durban branch, were from squatter camps. The report also states that scarce resources hamper the growth and development of children while poverty at home has also introduced stressors that impact on child care-taking. Family physicians are aware of the 7

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Open Forum effect of hampered growth and development of children, as a result of poverty, on their health and equally the effects of domestic social stressors on their physical and mental well-being. Family dysfunction and child abuse From observations and field experiences the majority of homeless street children in South Africa grow up in very fragmented families and household structures. Street homelessness among children, with its associated social consequences, is a manifestation of family dysfunction. Alcoholism, family disintegration and abuse constitute significant factors responsible for homeless, street child phenomenon in South Africa. For example, in interviews conducted in the Johannesburg metropolitan area, one of the street homeless girls interviewed said: "...I used to report to my mother that my grandfather is sexually molesting me but my mother would say not your grandfather but it is 'tokolosi'- an insect...". "...My mother's boyfriend used to abuse me when I was 6 years old because my mother is always sick and she is unemployed...". HIV/AIDS among homeless street children Children that are not infected are affected by HIV/AIDS. Those whose caregivers parents have AIDS are profoundly affected. The 2001 State of the Nations children's report hinted that child headed households due to HIV/AIDS is appearing with the average age of house head estimated at 11 years. Some children have also lost their shacks/ houses to extended families claiming they have no rights to their housing, hence rendered homeless. A street boy indicated: "...I am 10 years old and my sister is 7 years. My mother died of AIDS last year and we had nowhere to go. We came to town hoping to get some means for food. I sleep under the bridge and scavenge daily for food. I don't know where my sister is now...". In another street girl's response, she said: "...My mother is living HIV/AIDS and her boyfriend has been sexually 8 involved with me so I think I have the disease...". Also in an interview a street children caregiver in the Johannesburg inner city expressed the following concern: "...HIV/AIDS is a major contributing factor to high mortality rate among children. 8 deaths relating to HIV has been reported within the last 2 months in the inner city..." Table II indicates the rights of children living with HIV/AIDS30. cians will soon begin to encounter these group of children in their practices. It is most appropriate, now, to start stimulating discussions among family physicians on what roles they could play and assistance they could offer this category of children rather than this article putting forward a panacea. However the following are some specific areas within which family physicians' roles and professional assistance could be defined. Table II: Children's Rights and HIV/AIDS ⚫ HIV/AIDS are highly stigmatized conditions and there are many instances of discrimination against sufferers and their families. • In terms of the constitution every child has the right to be treated equally, therefore no one may discriminate against children with HIV or AIDS or those affected by it. ⚫ Children with HIV/AIDS have the right to be adopted, to foster care, to be placed in residential care and to basic education. • Children orphaned by AIDS are entitled to non-discrimination, consideration of their best interests, have survival and development rights including education, health, social security and appropriate alternate care. AIDS orphans and homelessness The State of the Nations children's report estimated the number of children under 15 years who had lost their mothers or both parents by the end of 1999 at 180000. Increasing orphans population is perhaps the most tragic and long-term legacy of the HIV/AIDS epidemic. Caring for orphans is one of the greatest challenges facing South Africa in future. The population of orphans under 15 years of age was projected to be around 800000 by 2005; rising to more than 1.95 million in 2010. Projections for year 2005 suggests that there would be 1 million AIDS orphans due to HIV/AIDS and 2 million by 2010. The death of a parent can result in loss of the home, children being left in the care of grand parents and or extended family. Some of these children, without proper parental care and guidance with the increased burden of survival or thriving, end up living on the streets, indulging in substance abuse or engaged in prostitution. What family physicians can offer The combined effect of HIV/AIDS, family dysfunction and poverty on the homeless street children remains a significant source of health problem. At the primary level of care family physiApplication of family medicine principles and practices Family Medicine, as a clinical discipline, in its uniqueness, prepares family physicians to look at health and healthcare beyond biological and physical boundaries. The principles and practices of Family Medicine emphasise the primacy of the person, understanding problems in their contexts and the importance of participating in community-wide network of support and healthcare agencies. Guided by these principles a lot could be done to alleviate the suffering of the homeless street children. Updating and expansion of knowledge This includes self-education, learning from professionals in other disciplines, and sharing experience with colleagues. It is particularly important for family physicians to be quite knowledgeable in counselling and the management of HIV/AIDS, child abuse, and STD. Expertise acquired in these areas will better prepare family physicians to deal with a whole range of problems associated with street homelessness among children. Thinking family Family dysfunction has been identified SA Fam Pract 2003;45(2)

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Open Forum as an outstanding cause of street homelessness with its associated problems. "Thinking family" would increase the possibility of identifying vulnerable families by family physicians when they are in contact with them. The practice of thinking family would serve as a very powerful preventive strategy for street homelessness among children and its related problems. Awareness For us to be aware is for us to seek and have insight into the problem. When we are aware then we can be sensitive enough and act appropriately. Family dysfunction, poverty and HIV/AIDS among street children is a reality in our society and Family Medicine and family physicians have to respond. Community-wide network Participation in community-wide network of support and healthcare agencies is an avenue to contribute and influence positive moves towards HIV/ AIDS prevention programmes, poverty reduction initiatives, supportive street homeless initiatives and child abuse preventive programmes. Comprehensive care The ability and readiness of family physicians to provide care and deal with any kind of health problems in these children underpins the comprehensiveness of the care they can provide. According to McWhinney34 "since family physicians are available for any type of health problems, the care they provide is comprehensive. They will never say to a patient I am sorry but your problem is not in my field. You will have to see somebody else". CONCLUSION Many children have become street homeless as a result of combined social problems of family dysfunction, poverty and child abuse. These children have turned to survival sex among other means of coping and this in turn exposes them to contracting STD and HIV/ AIDS. It is important to address absolute poverty, child abuse, family dysfunction and HIV/AIDS holistically in order for South Africa and Africa, for SA Fam Pract 2003;45(2) that matter, to avoid a missing generation and a population of orphans. Family Physicians have critical roles to play and contributions to make in this regard. They are in the vantage position of rendering comprehensive, especially preventive care. They could also be involved in other social and communitynetwork activities directed at improving the health of the homeless street. children. References 1. 2. Brown, R. Lester, HIV Epidemic Restructuring Africa's population: A Missing Generation-a population of orphans-a shortage of women. S.Afr Fam Pract 2002; 25(1): 2-3. Richter, L. "Street Children: The Nature and Scope of the Problem in South Africa", Child and Youth Care, 1988, 17 (1), pp 4-6. 3. Olufemi, OA, Feminisation of Poverty among the Street Homeless Women in South Africa, Development Southern Africa, 2000, vol. 17, no. 2 June, pp 221-234. 5. 6. T & 9. Nkoma, M and Olufemi, OA, "Educating street and homeless children in South Africa: Challenges of Policy Implementation", Special Issue, International Journal of Educational Policy, Research and Practice, Winter, 2001, vol. 2, no. 4. pp 337-356. Glasser, L. Homelessness in a Global Perspective. New York, Macmillan, 1994, p. 54. Olufemi, OA. Street Homelessness in Johannesburg innercity: A preliminary Survey, Environment and Urbanisation 1998, 10 (2): 223-234. Department of Social Welfare and Population Development (DSWPD), 1998, Policy and Strategic Guidelines on Street Children in South Africa, Republic of South Africa. United Nations Centre for Human Settlements (UNCHS), Strategies to Combat Homelessness. 2000, Habitat report, Nairobi, Kenya.pp xvi-xvii. Ritchie, M, Children in especially difficult circumstances: children living on the street. Can their special needs be met through specific legal provisioning? Consultative paper prepared for the South African Law Commission, February 1999, p. XII. 10. Richter, L., "Street Children: The Nature and Scope of the Problem in South Africa", Child and Youth Care. 1988, 17 (1), pp 4-6. 11. Richter, L. and M. van der Walt, "The psychological assessment of South African Street children", Africa Insight, vol. 26, no. 3, 1996, pp. 211-220, 12. Schurink, E. and Schurink, W., "Street Smart: facing the problem of street children", Social Update, Third quarter, vol.3, no. 3 1993., pp 13- 22. 13. Swart, J., The Street children of Hillbrow, Johannesburg: Witwatersrand University Press, 1990, p. 26. 14. Olufemi, OA, "Barriers that disconnect homeless people and make homelessness difficult to interpret", Development Southern Africa, vol.19, no. 4. October 2002 forthcoming. 15. Scharf, W.; Powell, M.; Thomas,E. "StrollersStreet Children of Cape Town, in S. Burman and P. Reynolds (eds.) Growing up in a Divided Society, Johannesburg: Ravan Press 1986. 16. The State of the Nation's Children Report, Children in 2001 A report on the State of the Nation's Children: National Programme of Action for Children in South Africa, The Office on the Rights of the Child, The Presidency, Union Buildings, Pretoria, 2001:21. 17. The State of the Nation's Children report, Children in 2001 A report on the State of the Nation's Children: National Programme of Action for Children in South Africa, The Office on the Rights of the Child, The Presidency, Union Buildings, Pretoria, 2001:27. 18. Draft Green Paper Department of Social Services and Population Development, Draft Green Paper: Towards a National Child Labour Action Programme, Johannesburg 2000:41. 19. Schurink, E. and Schurink, W., "Street Smart: facing the problem of street children", Social Update, Third quarter, vol.3, no. 3 1993, pp 13- 22. 20. National Programme of Action, A National Programme of Action for Children in South Africa: An outline, National Children's Rights committee. 16 June 1994:34. 21. The White Paper on Welfare Department of Welfare, White Paper for Social Welfare, Pretoria, 1997. 22. Olufemi, OA, The Homelessness Problem: Planning, Phenomenology and Gender Perspectives. Unpublished Ph.D. thesis, Faculty of Architecture, University of the Witwatersrand, Johannesburg, South Africa, 1997. 23. Olufemi, OA. Street Homelessness in Johannesburg inner city: A preliminary Survey, Environment and Urbanisation 1998, 10 (2): 223-234. 24. The State of the Nation's Children Report, Children in 2001 A report on the State of the Nation's Children: National Programme of Action for Children in South Africa, The Office on the Rights. of the Child, The Presidency, Union Buildings, Pretoria, 2001:125. 25. Schurink E. and Schurink, W., "Street Smart; facing the problem of street children", Social Update, Third quarter, vol.3, no. 3 1993, pp 13- 22. 26. Nkomo, M. and Olufemi, OA. "Educating street and homeless children in South Africa: Challenges of Policy Implementation", Special Issue, International Journal Of Educational Policy, Research and Practice, Winter, 2001, vol. 2, no. 4. pp 337-356. 27. The State of the Nation's Children Report, Children in 2001 A report on the State of the Nation's Children: National Programme of Action for Children in South Africa, The Office on the Rights of the Child, The Presidency, Union Buildings, Pretoria, 2001:125. 28. The State of the Nation's Children Report, Children in 2001 A report on the State of the Nation's Children: National Programme of Action for Children in South Africa. The Office on the Rights of the Child, The Presidency, Union Buildings, Pretoria, 2001:88. 29. The State of the Nation's Children Report, Children in 2001, A report on the State of the Nation's Children: National Programme of Action for Children in South Africa, The Office on the Rights of the Child. The Presidency, Union Buildings, Pretoria, 2001:125. 30. The State of the Nation's Children Report, Children in 2001, A report on the State of the Nation's Children: National Programme of Action for Children in South Africa, The Office on the Rights of the Child, The Presidency, Union Buildings, Pretoria, 2001:85. 31. The State of the Nation's Children Report, Children in 2001, A report on the State of the Nation's Children: National Program-me of Action for Children in South Africa, The Office on the Rights of the Child, The Presidency, Union Buildings, Pretoria, 2001. 32. ABT Associates, The Impending Catastrophe: A Resource Book on the Emerging HIV/AIDS Epidemic in South Africa, 2000. 33. ABT Associates, The Impending Catastrophe: A Resource Book on the Emerging HIV/AIDS Epidemic in South Africa, 2000. 34. McWhinney, Ian R.: A Textbook of Family Medicine, Oxford University Press, New York, 1989:19. 9