Geneva, Palais des Nations - May 3-6, 2000
CITIES OF THE SOUTH:
SUSTAINABLE FOR WHOM?
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ESF/N-AERUS International Workshop Geneva, Palais des Nations - May 3-6, 2000
CITIES OF THE SOUTH:
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K. Wyss, L. Nodjadjim
Swiss Tropical Institute, Basel - Centre de Support en Santé Internationale, N'Djaména - Association Pour la Protection des Enfants de la Rue au Tchad
Street children are one of the new categories of social actors resulting from the rapid urbanisation of cities of the South. Among the numerous problems they have to face daily, there are also obstacles related to disease and access to health care. This paper describes at the example of N'Djaména (Chad), their health problems as well as efforts to provide better health care through an action research approach.
Rapid urbanisation in the South and the growth of economic and social disparities and contradictions within urban societies produces new actors. Among the most visible people, are marginalised groups such as the disabled, drug addicts and street children. Since 1994, the Support Centre for International Health of the Swiss Tropical Institute (STI) accompanies two associations (Association Pour la Protection des Enfants de la Rue au Tchad, APPERT; Association Amies des Drogués au Tchad, ATAD) in their efforts to prevent social exclusion and reintegrate street children. This happens through action - research activities within the project "management of deprived urban areas by their inhabitants" financed by the Swiss National Science Foundation and the Swiss Agency for Development and Cooperation (Ndiaye, 1999; Yémadji et al, 1999; Wyss, 1999)
The approach of social work in an open milieu is favoured for contesting the exclusion of street children and young adults. This approach consists of contacting and accompanying the children in their natural living conditions and of developing jointly community based answers to their situation. Activities rely most importantly on the situation of boys as the exclusion of girls is more hidden, less visible and more difficult to tackle. The approach tries also to take into consideration and to encompass the whole range of problems: scolarisation, violence, nutrition, working conditions, repression, etc. but also health related aspects and access to health care.
The numerous and frequent illness episodes street children are confronted with, are the result of their living conditions and of various behaviours adopted by them. A child in N'Djaména testifies: "Matters giving disease to us are: mosquitoes, food found in garbage places, meals poisoned or picked up in the street. … We have to sleep on the street …. We sniff glue on pieces of dirty cotton". In other words, the consumption of unsanitary water, hygienic conditions, food, violence, alcohol and drugs have disastrous consequences on the health status of the children and young adults and result in various and frequent health related problems. The children most frequently mention (Levaque, 1998, Naodjiadjim, 1995; Nodjiadjim and Wyss, 1999): injuries and wounds, malaria, diarrhoea, muscular and abdominal pain, jaundice, conjunctivitis etc. In direct conversation the street children and young adults rarely refer to sexually transmitted or mental disease although it can be assumed that they affect their health status in an important way (Gounangbé, 1997).
Regarding health care, street children in N'Djaména most frequently rely on self-medication and express strong difficulties in access to public health services. The frequent acquisition of pharmaceutical products at the level of small boutiques and street sellers reveals on one side their meagre financial resources and on the other side the omnipresence the of urban "informal" economy. Furthermore, the possibility of procuring drugs in small units presents the advantage for children not to have to stock the products, but to be able to consume them immediately. Public and private health services are very difficult to access due to the absence of financial assets for paying the services and due to psychological barriers related to the negative attitude of health workers towards the street children.
In N'Djaména, these research activities on the health status and problems as well as on the access to health care accomplished since 1994, become catalytic elements of a research process for identifying operational and feasible solutions for health related obstacles of street children and young adults. At the very beginning, APPERT and STI decided to feed-back study results to health workers and professionals at the Ministry of Health. These working sessions allowed to inform and sensitise them on the importance of issue and on the need for providing health services without discrimination to children in fragile conditions. These exchanges resulted in the establishment of a contract with two services of the city. An animator was appointed for clearing formalities and keeping update registries, for the orientation and guidance of the children to the dispensary as well as for the follow-up. On the other hand, information provided by research results allowed authorities (city medical officer of health, physicians, in charges, etc.) to understand that at the level of marginalised people serious health problems do exist, making it necessary to remove barriers in order to facilitate the access to the services. Unfortunately, the solution of establishing contracts with the dispensaries was not sustainable, mainly du to resistance at the level of health workers towards street children and young adults. On the side of the children and young adults, mistrust towards the providers played also an important role.
Subsequently other solutions were discussed and implemented. A missionary structure temporarely was willing to welcome the most urgent cases. In parallel, APPERT identified a medical officer and started to organise visits and treatments for the street children directly at the places frequented by them. Concomitant, a permanent availability of drugs allowed to tackle and solve health problems in a significant way until today.
Thus it became possible through an action research approach to identify various, more or less sustainable solutions for curative care. Opposite, it was more difficult to identify approaches for preventive measures for example through health education. Cleaning the body, avoiding to eat spoilt food found in the garbage, washing the hands before eating, do simply not make part of attitudes of living in the street. For respecting these hygienic rules and in order to prevent health problems, time and better general conditions are necessary. Street children are by definition mobile and time is for them a scarce resource for finding resources in their daily struggle for survive.
Results of activities for providing better health care to marginalised groups revealed the potential of an action research approach for (1) contesting the exclusion of street children and young adults by social work in their natural milieu (2) developing and identifying jointly community based answers to the situation, (3) acquisition and exchange of knowledge, and change / development at the micro- and meso-level. Activities showed also how collaboration, partnership and communication between street children and institutional actors may govern sustainable management of the urban environment in the South.
Gounongbé A (1997). Quand le désir de soigner rjoint le désir de se soigner. Psychopathologie aficaine 28 (3): 313-338
Levaque L. (1998). Etude qualitative portant sur les problèmes de santé des enfants des rues de N'Djaména et leur recours aux soins Research report: Swiss Tropical Institute, N'Djaména, Chad
N'Diaye M (1999). Recherche populaire. In: Environnement urbain - recherche et action dans les pays en développement (Eds: Bolay JC, Odermatt P, Perdrazzini Y, Tanner M). Birkhäuser, Basel: 23-28
Nodjadjim L. (1995). Etude sur les conditions de vie et le recours aux soins chez les enfants de la rue à N'Djaména. Research report: Swiss Tropical Institute, N'Djaména, Chad
Nodjadjim L and Wyss K (1999). « Les choses qui nos donnent les maladies ». Bulletin Medicus Mundi 75 : 16-17
Yémadji N, Allassembaye D., Laoubaou AN, Bachimon P, Jeannée E, Wyss K (1999). La recherche - action - formation appliquée à la gestion d'un espace urbain défavorisé. In: Environnement urbain - recherche et action dans les pays en développement (Eds: Bolay JC, Odermatt P, Perdrazzini Y, Tanner M). Birkhäuser, Basel: 143-154
Wyss K (1999). Recherche - Action - Formation à N'Djaména. In: Environnement urbain - recherche et action dans les pays en développement (Eds: Bolay JC, Odermatt P, Perdrazzini Y, Tanner M). Birkhäuser, Basel: 137-142
N-AERUS: Network-Association of European Researchers on Urbanisation in the South
http://www.naerus.net