Accepted Manuscript

Health crises, social support, and caregiving practices among

street children in Bangladesh

M.D. Hasan Reza, Julia R. Henly

PII: S0190-7409(17)30874-5
DOI: doi:10.1016/j.childyouth.2018.03.006
Reference: CYSR 3722
To appear in: Children and Youth Services Review
Received date: 7 October 2017
Revised date: 3 March 2018
Accepted date: 3 March 2018

Please cite this article as: M.D. Hasan Reza, Julia R. Henly , Health crises, social support,
and caregiving practices among street children in Bangladesh. The address for the
corresponding author was captured as affiliation for all authors. Please check if
appropriate. Cysr(2017), doi:10.1016/j.childyouth.2018.03.006

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 ACCEPTED MANUSCRIPT

Health crises, social support, and caregiving practices among street children in Bangladesh

Author 1:

Md. Hasan Reza, Ph.D

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Assistant Professor

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Indiana University School of Social Work, South Bend
Wiekamp Hall, 2219

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1800 Mishawaka Ave
PO Box 7111
South Bend, IN, USA, 46634
Email: rezam@iusb.edu

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Phone: 574-520-4639
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Author 2:
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Julia R. Henly
Associate Professor
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School of Social Service Administration

The University of Chicago
969 E. 60th Street
Chicago, IL, 60637
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jhenly@uchicago.edu
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Author Note: This research was partially supported by Armin Scheitacker of Germany and the Fahs

Beck Foundation of New York, USA. We are grateful to study participants for sharing their stories,

and to valuable feedback on an earlier draft from two anonymous reviewers.

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Abstract

An estimated 1-3 million children live on the streets of Dhaka, Bangladesh relying on each other

for survival in an environment characterized by illness, violence, and poverty. Research has

rarely examined the everyday caregiving environment of street children in Bangladesh or how

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they survive the illness and injury so common to their experience. To understand street

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children’s caregiving practices, this paper draws in part from the informal caregiving and social

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support literatures. The qualitative project purposively selected 75 street children and asked three

primary questions: 1) What is the nature of crisis children encounter on the street? 2) What are

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the ranges of informal caregiving practices? 3) What social network characteristics facilitate or
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complicate caregiving? Findings suggest that street children encounter unprecedented dangers

and experience frequent accidental injuries and repeated episodes of sickness. They rely mostly
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on social network members for a range of supports. Network members, primarily peers, help
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devise a treatment plan, accompany them to treatment centers, buy medicine and nurse sick

youth. Network members bear most treatment, food and other expenses and usually do not
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expect immediate repayment. Street children offer support to close and weak network ties,
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however support is more intense for friends. Caregivers also struggle to balance their own life

and work while engaged in caregiving practices with evidence of detrimental effects on
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friendship ties in some cases.

Key Words: Health crisis, social relations, social support, street children, Bangladesh

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1. Introduction

Millions of children survive on the streets of large cities in the developing world, where they

face immediate crises over food, shelter, and physical safety that threaten their health and

wellbeing. Illness and injury are commonplace, a regular part of children’s life on the street (Hai,

2014; Patwary, O’hare, & Sarkar, 2012). Children who survive on the street are extremely low

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income – poverty is often a key push factor that drives them (and sometimes their families) to

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migrate to urban centers in the first place (Aptekar, 1988; de La Barra, 1998; Evans, 2004; Reza,

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2016). Once there, their jobs, living arrangements, daily activities, and physical circumstances

put them at extreme danger (Pinzon-Rondon, Koblinsky, Hofferth, Pinzon-Florez, & Briceno,

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2009; Reza, 2017) and require them to engage in high-risk survival behaviors (Hills, Meyer-
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Weitz, & Asante, 2016; Sherman, Plitt, ul Hassan, Cheng, & Zafar, 2005), resulting in high rates

of injury and health problems (Ali & de Muynck, 2005; Uddin, Sarma, Wahed, Ali, Koehlmoos,
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Nahar, & Azim, 2014). For example, research from developing and middle-income countries
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demonstrate that many street children are forced to accept survival sex and other hazardous work

in exchange for money, drugs or shelter. They experience physical injuries, violence, verbal
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abuse, and financial exploitation perpetrated by adults, peers, clients, and members of law
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enforcing agencies (Nada & El Daw, 2010; Ribeiro, 2008; Woan, Lin, & Auerswald, 2013).

Living in a hazardous environment often exerts a high toll on their physical health. For example,
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evidence shows that parasitic, bacterial, and hepatic infections are higher among street children

than housed children; and they suffer elevated rates of fever and respiratory, skin, and digestive

conditions (Njord, Merrill, Njord, Pachano, & Hackett, 2008; Greksa, Rie, Islam, Maki, & Omri,

2007; Parveen & Faisal, 2005). As well, due to early sex initiation and unprotected sex, the

prevalence of sexually transmitted infections (STI) is higher for street children (Bal, Mitra,

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Mallick, Chakraborti, & Sarkar; 2010; Towe, Hasan, Zafar, & Sherman, 2009). A similar gloomy

scenario persists concerning their mental health. Due to chronic exposure to various stressors,

street children experience high levels of hopelessness and depressive symptoms, and suicidal

thoughts (Asante, Myer-Weitz, & Petersen, 2015; Pluck, Banda-Cruz, Andrade-Guimares,

Ricaurte-Diaz, & Borja-Alvarez, 2015; Seager & Tamasane, 2010). Furthermore, research shows

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that some street children experience substance abuse problems, ingesting various dangerous

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chemicals such as paint thinner, glue, and toluene to curb hunger, numb emotions, and for

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pleasure (Elkoussi, & Bakheet, 2011; Praveen et al., 2012; Seth, Kotwal, & Ganguly, 2005).

To date, there has been limited investigation of the ways that children living on the street

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respond to physical and mental health crises that require caregiving attention. Little is known
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about the health care decision-making of street children or how they take care of themselves and

other children on the street. This would seem an important gap in existing research, given the
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aforementioned elevated health problems experienced by children on the streets and given
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financial and other barriers to accessing formal healthcare services (Mahmud, Ahsan, & Claeson,

2011).
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The existing literature that examines the healthcare domain and caregiving needs of street
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children (and homeless children more broadly) sometimes presupposes the existence of a family

caregiving environment or, in the absence of such, the existence of an institutional caregiving
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infrastructure available to intervene in response to health and mental health needs (Imasiku &

Banda, 2015; Watters, & O’Callaghan, 2016). For example, one study found that parents were

influential agents in the healthcare decisions of street children (Ali & de Muynck, 2005),

although this study was based on a sample of Pakistani street children in the cities of Rawalpindi

and Islamabad who worked on the street but resided predominately with their families of origin.

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Other studies emphasize the relevance of formal services in responding to the caregiving needs

of street children. For example, a Burundian shelter successfully reduced former street children’s

physical health complaints (Crombach & Elbert, 2015). Other health related interventions (e.g.

health services in drop-in-centers; street outreach, or interagency collaboration) have been tried

in many developing countries, and some have shown evidence of successfully delivering crucial

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health services to children who hardly have any ties with their families (Saalam Baalak Trust,

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2017; Scivoletto, da Silva, & Rosenheck, 2011).

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Beyond family support and institutional services, there is reason to believe that the

“street” networks of children may be primary responders to the health crises that impact their

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health and wellbeing. By street networks, we mean the constellation of individuals other than
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formal service providers and immediate family members that children interact with for survival

on the street, especially but not limited to their peers. For example, street networks may include
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friends, employers, and in some cases even customers of children working on the street. Some
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North American studies document the creation of fictive families among homeless youth who

tend to provide safety and protection in times of need (McCarthy, Hagan, & Martin, 2002; Smith
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2008, Tylor, 2008). The notion of protection is also evident in studies of street children in
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developing countries. For example, two studies showed that Bangladeshi and Indonesian street

children formed intimate and hierarchical groups with other street children to safeguard each
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other from street adversities and abuse from hostile groups (Beazley, 2003; Reza, 2017). These

and a few other studies (i.e. Erickson & Mulugeta, 2015; Mizen & Ofosu-Kusi, 2011, Aptekar,

1988) have focused specifically on social relationships and peer support on the streets without

addressing health and caregiving needs per se. A few additional studies have examined the

influence of homeless and street youths’ peer relationships on mental health and other health-

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related outcomes. For example, studies in North America found that friendships in pro-social

networks may lower sexual risk-taking and anti-social behaviors, and help improve mental health

outcomes through information exchange, peer counseling, and instrumental support (Rice,

Milburn, & Rotheram-Borus, 2007; Rice, Stein, & Milburn, 2008; Rice, Kurzban, & Ray, 2012;

Unger et al., 1998). Overall, however, there remains very limited attention to the question of

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whether and how the social networks of street children support one another in response to health

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crises within the context of developing countries.

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The current paper considers the ways in which street children living in Dhaka,

Bangladesh care for themselves and others in the face of health crises. It explores the nature of

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the health crises that street children encounter and the sources (formal services, family supports,
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and street networks) of support available to manage a crisis. We pay particular attention in our

analyses to the role of street networks in caregiving support and the potential costs and risks to
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social relationships incurred as a result of caregiving practices among street children.

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2. Background

21. Street Children– Definition and Estimated Size in Bangladesh

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Widely divergent definitions of street children emerge from the varied perceptions and
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connotations of researchers, academics and practitioners who use the generic term to cover a

heterogeneous group of children with diverse demographic, social and economic characteristics
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(Aptekar, 1994; de Benítez, 2011, Lusk, 1989). Some researchers prefer definitions that highlight

different social criteria, including family involvement of street children (Cosgrove, 1990), their economic

engagements within the urban environments (Connolly & Ennew, 1996), and their risk categorization

(LeRoux & Smith, 1998). A challenge that such heterogeneity in definition poses is estimating the

number of street children, particularly in countries where child labor is widespread. In Bangladesh,

UNICEF estimates that the number of street-living children is 1.1 million. This estimation reaches up to 3

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million when street-connected children, especially those who use street and public places to generate

an income but may nevertheless reside with their families, are taken into account (Barkat, Poddar,

Rahman, Mahiyuddin, & Halim,2009). Regardless of their actual number, there is hardly any debate that

an increasing number of young children are migrating to the urban areas in Bangladesh in search of a

livelihood. For the purposes of this paper, our focus is on children not living with their families, who

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reside on the street or in some cases with a temporary housing agency or shelter in Dhaka, Bangladesh.

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Given this definition, and the limited social service infrastructure in Dhaka, we suspect that family

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support will be limited for these children and that there will be few formal services to respond to the

caregiving needs of children in the face of a health crisis (Mahmud, Ahsan, & Claeson, 2011).

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2.2 Social Networks and Social Support Concepts
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Drawing on key themes from social capital and social network research, we consider the nature and quality of social

ties that may best support the caregiving needs of street children experiencing a health crisis. Research suggests that
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social networks consisting of close ties—those characterized by frequent interaction, a high degree of emotional

intensity and intimacy, and that are reinforced through reciprocal exchanges—serve an expressive function that
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helps to preserve a network’s resources, facilitate coping, and aid survival (Lin, 2001; Granovetter, 1983; Briggs,

1998; Putnam, 1995; Coleman, 1988; Uehara, 1990). The principle of homophily suggests that people are likely to
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form close ties with others similar to themselves (McPherson, Smith-Lovin, & Cook, 2001). This similarity may
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encourage affection and intimacy that motivates interpersonal interaction and promotes acts of caregiving, but that

also limits the novelty of information and opportunities that are shared across the network. This conceptualization of
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close ties is akin to the notion of “bonding social capital” (Putnam, 1995) that has received considerable attention in

the social capital field.

Research suggests that it may be relatively easy to activate assistance from close ties in times of need

(Granovetter, 1973; 1983; Putnam, 1995). Close ties may help one another without expectation of immediate return

and without a careful accounting of credits and debits, given the longevity of the relationship and the personal

investment and emotional bond that governs it (Uehara, 1990; Antonucci, 2001). The value of close ties may be

greatest when individuals are in high-stress environments, in need of urgent help, and highly dependent on one

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another (Burt, 2009; Lin, 2001; Stack, 1974). Research demonstrates both the strengths and the challenges that

highly impoverished communities pose for the development and longevity of close, reciprocal ties (Stack, 1974;

Offer, 2012). Family-based ties are often assumed to represent close ties; however, we reason that street children—

especially those with marginal or severed ties with family members—may develop close ties with other street

children, even forming fictive family groups over time (Aptekar,1988; Swart, 1990; Smith, 2008). In fact, some

research demonstrates that fictive families often mimic the role of traditional families and provide economic,

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emotional, health care support in addition to protection and a feeling of belonging that is absent in children’s street

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life (Smith, 2008; Trussell, 1999). These supportive relationships function within a context of very scarce resources

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and amid high competition. As a result, although relationships may be close, they may also be burdened and

conflictual, possibly resulting in a weakening or breaking down in relationships over time (Hagan & McCarthy,

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1998). Evidence from some studies suggests that older children can become physically abusive towards younger

group members when young members fail to comply with the demands of the older ones (Heinonen, 2011).
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Moreover, sexual relationships among street youth can be abusive, exploitative and hierarchical, demonstrating

positions of power and age stratification within a peer group (Aptekar & Ciano, 1999; Beazley, 2003).
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Social network and social capital research also recognize the unique value of weak ties—
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relationships in which individuals are less familiar, where interactions are less frequent, with less

intense emotional bonds. According to some social network research (e.g., Granovettor,
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1973;1986; Briggs, 1998), these weak ties have a structural tendency to provide better (or more
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novel) information to an individual – serving as bridges to new opportunities – because the weak

tie is likely to have characteristics and experiences that are unique from those of an individual’s
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close ties. Not all weak ties are bridges, however (Lin, 2001; Granovetter, 1973;1983). Although

weak ties connect people to individuals outside of one’s immediate and intimate circle, these

network members may not hold information or resources that are substantively different or more

useful than what is available from close ties. Moreover, the structural link to these ties on its own

does not guarantee the weak tie will be activated. To the extent that the networks of street

children include weakly linked ties to individuals who hold and are willing to provide useful

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information, access, and resources to treat health problems, these kinds of ties might be

beneficial for children living on the street.

The social networks of street children may include a combination of close and weak ties;

however, there is reason to believe that close ties dominate their networks and that the weak ties

that do exist may be limited in their willingness or ability to help respond to healthcare crises. In

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particular, we suspect that street children develop at least some close ties with the peers with

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whom they work, live, and play on a daily basis. These children may develop strong emotional

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bonds, help one another find jobs, protect one another, and play games together – and, of

particular import for this study, offer caregiving in response to a healthcare crisis. Thus, bonding

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social capital may be present for street children. Street children may also have weak ties to other
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street children with whom they may not know well (perhaps they reside in another neighborhood

of the city) or with whom they are in direct competition for scarce resources. Although these
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children are not intimate with one another, and may be considered weak ties, they nevertheless
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are likely to have considerable overlap in their personal characteristics and share a low social

status. Thus, it seems unlikely that the existence of such weak ties can be used to leverage
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caregiving support that is different or appreciably better than that available from existing close
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network ties (Lin, 2001). On the other hand, it is possible that within the street networks of

children are weak ties to individuals with diverse and useful resources that may serve as bridging
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social capital: for example, ties to employers and city residents, especially adults of a higher

status, with whom casual interaction occurs on a regular basis. These individuals may represent

vertical ties that provide useful information about how to treat a particular health care problem

and possibly provide transportation or financial support that allows them to take advantage of

health care services outside of what might be available from within a peer network. Existing

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research suggests, however, that the relationships that street children have with their employers

and other adults in the community can be exploitative, abusive, and fragile. There may be limited

need or desire for an employer to come to the aid of a street child in need, especially in the

context of surplus labor as is the case in many cities in the developing world (Frnakland, 2007).

Adults with whom a street child gets to know on a casual basis may also have limited reason to

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provide support, although they may do so out of friendship or empathy for the child. Thus,

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although there is a potential for weak ties to be a source of bridging social capital to street

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children, there is reason to believe that the weak ties available to this population will not serve

such a positive function.

3. Methods
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The current study examines the caregiving experiences of 75 children living in the streets
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of Dhaka, Bangladesh in response to health crises. The data are derived from a qualitative

interview study that explored street children’s economic and caregiving strategies, with
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particular attention to their use of social networks as a means of survival on the street.
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3.1 Research sites

Dhaka is the most populated city in Bangladesh and a major hub of the country’s
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economic activity. As such, Dhaka is a destination city that attracts many street children from
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across the country. The researcher initially scouted six locations within the city to center the

study’s data collection and ultimately selected three sites because of their strategic position for

street children (e.g. access to informal jobs, available public space). These locations are the

central railway station in Kamalapur, a river port in Sadarghat, and a market place in Karwan

Bazar.

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Kamlapur and Sadarghat host the largest number of street children in the city (Bashir,

2009), especially for new arrivals. Sadarghat is the main entry point that connects the southern

and the coastal regions of the country. It is also the cheapest route for the children who leave

home to come to Dhaka. Kamlapur train station is also a central transport hub for arriving

children and street children use local trains from Kamlapur to travel to and from the city. Both

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Kamlapur and Sadarghat are major sites of street children’s employment, which also influenced

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our decision to focus data collection there. Additionally, in scouting sites, the researchers noted

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that female street children tend to especially congregate in both Kamlapur and Sadarghat,

possibly because the presence of security and police in those spaces may lend a sense of relative

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safety. The Karwan Bazar, the third research site, is situated next to a major intersection and is
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heavily trafficked as one of the busiest markets in the city—featuring groceries, fish, and kitchen

supplies. Karwan Bazar draws many street youth in search of a source of livelihood.
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3.2 Sampling
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Purposive sampling was used to select study participants within the three sites. Two

strategies were used to recruit participants. First, program participants from two service agencies
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were verbally invited to participate in the study. The invitation resulted in 40 younger
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participants (10-14 years old). A second strategy — snowball sampling — was followed to

include older children between 15 and 17 years old. In a few instances, the research team
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approached and recruited directly from the street. A total of 75 children, 59 boys and 16 girls,

were recruited and participated in the study.

3.3. Data Collection Instruments

A semi-structured in-depth interview protocol was used to guide interviews with each

participant. All interviews were conducted by the study director (the co-Principal Investigator)

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and two research assistants. The interview protocol contained some closed-response questions

but most questions were open-ended and prompted conversational exchange between the

interviewer and the participant about the key topics of interest. The primary topics included:

employment experiences, transition experiences from home to street, support exchanges in

networks, reciprocity. To aid collection of information regarding a child’s social network, the

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interviewer used a method known as the hierarchical mapping technique (HMT) (Antonucci,

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1986). With HMT, the interviewer shows the participant a diagram of a set of three concentric

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circles, with the middle circle representing the participant him or herself. The participant is

instructed to think of each circle as representing the people in their lives, of various degrees of

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closeness, that are important to them and that help as well as challenge their everyday life.
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Together, the participant and the interview place each person in the corresponding circle and

throughout the process, the participant talks about the ways the person is important to them, the
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intensity of the relationship, and how he or she helps and/or gets in the way. For the current
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study, the interview protocol was developed in child-friendly Bangla, which is the only language

street children use for communication. The HMT diagram was slightly modified from the
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original to include drawn faces of boys and girls and men and women (of various ages)
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throughout the circles, in order to make the diagram more child-friendly and understandable.

Both the protocol and the HMT diagram were tested and modified multiple times until the
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language and drawings were deemed sufficiently colloquial and child-friendly. Interviews lasted

for an hour or more depending on the child’s wish. In most cases, two interview sessions,

sometimes three, were required.

3.4 Data Collection Process and Ethical Consideration

The research project was approved by the institutional review board of a US university.

The research team (the principal investigator, co-principal investigator (study director), and two

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research assistants) adhered to ethical guidelines in every step of the research. Participants were

given information about the objectives, procedures, risks, and benefits of the study during

information sessions. Prior to the interview, a quiet place and time of participant’s choice (e.g. a

quiet railway platform, river bank, or non-governmental organization (NGO) shelter) were

selected. A verbal consent form was read to each participant during every session of the

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interview. During the interview, light snacks were served and frequent inquiries were made to

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learn whether they were comfortable. At the end of the interview process, each participant was

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paid $1.50 (equivalent to two-thirds of their daily income) for each session.

3.5 Data Analysis

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Demographic information (e.g., age, gender, education, family members) was extracted
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from each interview and entered into SPSS statistical software for descriptive quantitative

analysis. Nvivo 9, a qualitative data analysis software package, was used to facilitate analysis of
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the interview data. Specifically, a set of a priori codes were indicated by the research questions
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and the conceptual framework motivating the study. Another set of codes were then generated

that emerged from a careful, line-by-line reading of the interview text. Next, relationships among
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the codes were observed and grouped into larger themes or categories (Miles and Huberman
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1994; Ryan and Bernard 2000). Once initial coding was completed in Nvivo 9, corresponding

text around a theme or subtheme was gathered into a participant-by-code matrix to aid the
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identification of patterns across participants (Ryan and Bernard 2000). Matrices were carefully

examined to find similarities and differences in stories across participants, with frequent re-

reading of full interview transcripts to confirm the veracity of emergent findings.

Excerpted sections of relevant text are included to illustrate study findings. These excerpts were

translated into English by the study director, a native Bangla speaker. Cultural subtleties, meaning of

expressions, and contexts of conversations were considered in the translation process. (The original

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Bangla text is available from the author by request.) For reporting purposes, pseudonyms were used to

protect participants’ identity.

3.7 Study Limitations

Purposive sampling was used to identify a diverse group of street children with disparate

experiences. The non-representativeness of the sample, however, means that our findings are

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reflective of this select sample of participants and may not be generalizable to street children

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more broadly. Second, given the young age of some of our study participants (some were as

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young as 10 years old), it was sometimes difficult to hold an extended conversation about

complex subjects like social networks, health crises, and social support. Despite efforts to make

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the conversations informal, flexible, and as easy as possible on the children, there were instances
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when young participants struggled to respond to certain questions and this might have

compromised the richness of the data. It appeared that children’s ability to remember details of
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certain crisis events depended not only on age, but also on the intensity of the event and the time
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of the occurrence. Street children live in an almost constant crisis mode, which may challenge

memories of these more distant events. Third, a noted shortcoming of the study was the under-
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representation of female voices. This under-representation may have been due in part to the male
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gender of the interviewers. While all street children are vulnerable and have reason to be

skeptical of engaging in conversation with an unfamiliar person, girls may feel particularly so,
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especially in cross-gender interactions that may elicit additional uncertainty regarding the

intentions of the interaction partner. In a few cases, especially of older girls, the researcher

concluded that the participants were hesitant to share an elaborated perspective about their

experiences on the street. Finally, we would be remiss in not recognizing the power difference

between researchers and participants. This divide undoubtedly shaped both the information that

was communicated by participants and the interpretation of the data by the researchers. Other

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researchers have acknowledged that street children might provide socially acceptable narratives

regarding their accounts of life on the street (Conticini & Hulme, 2006). We are not sure to what

extent social desirability bias has impacted our data but we took measures (e.g. extensive rapport

building, informal triangulation) to minimize such bias.

4. Findings

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4.1 Demographics, Network Size, and Street Relationships

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Over half of the participants (54.7%) fell between 10 and 13 years old and over a third (37.3%)

were 13 to 15 years old. The participants varied greatly in their length staying on the street, from 6 to 96

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months (mean = 34.13 months). Almost all the participants had little or no education prior to street

migration and almost all of them came from an income poor background. They reported that their
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parents worked as day laborers, marginal farmers, rickshaw pullers and similar low-income occupations.
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About half of the participants (47%) reported that at least one biological parent had died at some point

prior to street migration.

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Children’s street networks were mostly comprised of non-family members (primarily other
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youth), who they had met during their time on the street, through jobs, at a shelter, or from interacting

in public places in the city. The HMT diagrams revealed that participants’ networks averaged 10.9
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persons. Non-relative members included a mix of peers and adults, both males and females. Participants

reported an average of over one adult in their network (mean=1.26); however, not all participants had a
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tie to an adult. A little over half (53%) reported an adult male and fewer (17.3%) reported an adult

female in their networks. Compared to adult members, participants had a large number of peer

relationships, accounting for over 85% of all network ties. The HMT diagrams and the discussion that

they elicited revealed that peer ties were distinguishable in terms of relational strength. Based on the

analysis of interviews, we divided the ties into two primary groups: friends and acquaintances. The

distinction between friend and acquaintance was made according to criteria developed based on a

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conceptualization of tie strength taken from existing social network studies and adapted to the current

context of street children networks (Aptekar & Stoecklin, 2014; Beazley, 2003). In the few cases in which

there was ambiguity about classification, it was resolved through further analysis and discussion of the

interview transcript between the two study authors. Friends represent what we refer to as “strong ties,”

those who reported being deeply committed to one other, had a relationship that was described as

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including some degree of trust, reported interacting with one another across different contexts (e.g.,

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sharing work, recreation, sleeping areas.) On average, participants reported 4.7 close ties. In contrast, a

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tie was considered “weak” and classified as an acquaintance when the relationship was described by the

participant as not intimate or close. These ties included peers who participants reported seeing around

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the streets, and, at the very least, peers that they could recognize by face, if not by name. These
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relationships did not meet the criteria of strong ties that would allow classification as a friend according

to the criteria used in this study. Participants reported an average of 4.9 weak ties. Of note, the street
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children interviewed in this study reported network ties that were quite homogenous in terms of
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gender. Boys were represented heavily in boys’ networks and girls were represented heavily in girls’

networks. However, boys’ networks appeared to be even more segregated by gender than girls’
PT

networks. For instance, boys listed only 2 female friends across the 59 male participants; whereas 22
CE

male friends were listed across the 16 girls in the sample. Nevertheless, for girls, the vast majority of

their listed ties were to other girls.

AC

4.2 Nature of Crises and Sicknesses on the Streets

As expected, the interviews revealed that street children suffer from frequent injuries and

sicknesses. The source of injuries and sicknesses could be attributed to three major factors: their own

risk-taking behavior, dangers from employment in informal jobs, and the unhygienic physical

environment in which they lived.

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Regarding the children’s own risk-taking, it was the research team’s observation that many

participants engaged in activities that could fairly easily lead to physical injuries. Whether it was weaving

through oncoming vehicles while crossing a road, riding on the roof of trains, or dangling from the back

of a city bus, the chances of injury appeared high. Hridoy, a 12-year old at Kamlapur, captured the way

the youth sometimes embrace the kind of risk that comes from having fun or navigating the city:

T
R: One day me, Alamain and Rajon climbed on the roof of the train. We were having fun. We

IP
all started dancing on the roof. We made a circle by holding hands and were dancing being
encircled. I did not notice that I was at the edge of the roof. I slipped down from there. Alamin
tried to hold me but he could not. Thanks to Allah that I fell on the ground. I could hit an iron bar

CR
next to where I fell. I got hurt in my head... It was bleeding...

The danger in the example above was not uncommon across sites. For example, one of the

US
study researchers observed in the Sadarghat that two street children crossed the busy river with a raft
AN
built of a huge pile of plastic soda pop bottles. One of them was pushing it from behind while swimming,

whereas the other rowed the raft with a flat piece of wood. When back on shore, one of the children
M

reported to the research team that the rowing child did not know how to swim.
ED

Participants’ job assignments and working conditions were another source of injuries and

sickness. For example, many children worked as day laborers on eight-hour shifts – cleaning, moving
PT

earth, handling construction materials, chipping bricks. Children who worked as laborers along side of
CE

adults were expected to keep up with the adult pace. The comments of one 13-year old day laborer

illustrate how the strenuous work could take a heavy toll on children’s bodies: “After work, I felt like a
AC

dead body. I couldn’t wake-up the next morning. I couldn’t move due to body ache… I quit.”

Job assignments were not only strenuous, they were often dangerous and could result in injury.

All participants reported sustaining at least one work-related injury within the prior six months of the

interview. For over one-fourth of the participants (n=22), injuries were so extensive that they had to

seek professional medical care and missed work for several days or weeks. For example, a participant

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from Sadarghat was hired to clean a sewage tank. While working, he slipped into the tank and almost

drown. His coworker, with help of others, rescued him and took him to the hospital.

The perilous physical environments where participants spend most of their time, and their

interaction within this environment, increased the probability of physical injury and sickness. Except for

four girls who used a shelter to sleep at night, all the other participants in this study slept on train

T
platforms, in roadside sheds or on road medians. The researcher team’s observation was that most of

IP
these places were filthy with dirt and trash and therefore unhygienic places for young children to sleep.

CR
Despite reports of frequent sicknesses and injuries, it was hard to compile how often and

what types of sicknesses street children suffered most. During the interviews, some participants

US
reported that they could not recount the frequency of minor sicknesses (such as fever, minor cut,
AN
flu). Thus, some of their experiences of sickness are likely to be underreported. The measure

taken to estimate children's illnesses and injuries was to count their visit to formal sources of
M

caregiving (e.g., hospital, local dispensary, or health care professionals). It was reported that all
ED

the participants from three sites visited one of these establishments at least once within the last

six months.
PT

4.3 Managing Crises and Sicknesses

CE

Sicknesses and injuries brought many challenges to street children beyond their usual

difficulties getting by on the street. Employment is critical for economic survival in this
AC

population. Succumbing to illness could result in reductions in earnings and, in turn, the food and

other basic necessities needed to sustain themselves. If the sickness was prolonged, street

children in the study reported not only losing the earnings necessary for basic survival but they

also reported needing more resources to obtain necessary health care. The strain on their finances

could become extreme at a time they were most needed. Seven participants reported especially

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difficult financial circumstances due to an extended illness. Jewel, a 14-year old at Kamlapur

shares his past predicaments:

"... I had this thing. At the beginning, I could not understand what it was. I felt weak and couldn't
eat anything. My eyes were yellow. Some kids told me that spirit [evil] got me...later I learnt that
I got jaundice...I couldn't do any work, always felt weak... bhai [brother], I suffered a lot
at that time - suffered with money, sleep, meal... how much will they [friends] help? I suffered
about a month and decided to go home...”

T
In order to overcome the crises associated with illness and injury, children would sometimes

IP
seek help from service providers or employers or in some cases return to their family to recuperate, as

CR
Jewel did. Participants indicated that these measures were neither favored nor usually available to

them. If they had experienced parental abuse or family disintegration returning to a parental home was

US
a difficult option. For instance, Rajib, a 15-year participant at Kamlapur, reported being raised by his
AN
grandparents after his parents died. He fled from his grandparents' home after being severely abused by

his grandfather and uncles. He said, "If I go there [being sick] they will peel my skin". But even children
M

who had maintained a good relationship with their families expressed reluctance to return home. They
ED

highlighted their parents’ financial inability to care for them. As Rasel, a 10-year old participant at

Sadarghat, shared, "... they [parents] can't manage three meals for my siblings [5 siblings], and how
PT

would they treat me?" Still other participants reported that they needed to travel a long distance to
CE

return home and that such travel required money, time, and a physical strength that would be difficult

to manage during such a crisis.

AC

In regards to seeking medical attention from formal services, there existed some institutional

support from government hospitals, private dispensaries, or NGOs (Non Government Organization) with

health centers. Some participants, especially in Karwanbazar, used these services with some regularity.

As we discuss further below, it was often friends who helped street children access formal medical

services or purchase medicines from dispensaries. Despite the availability of some formal supports,

participants reported that these services were quite limited. For example, participants reported that

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drop-in-centers were only able to provide first aid intervention for an injured child. Moreover,

participants reported that such services were not available after hours nor did they cover other aspects

of a crisis (e.g. income loss, meal support, and rehabilitation or nursing services during the recovery

period.) In the two other locations besides Karwanbazar, there was not a drop-in-center that was

conveniently located. In a serious accident, children mostly went to government hospitals that offered

T
some free medical care.

IP
The interviews suggested that a minority of street children were able to seek support from their

CR
employers. In most cases, employer ties did not reliably extend beyond the informal employment

relationship, however. Several participants did report that they sometimes borrowed a little money

US
from an employer to respond to a sickness. Shafique, a 12-year old at Sadarghat, shares his experiences:
AN
I: How does Mahajan [employer] help you?
R: ... Sometimes, if I am sick he would give me few takas to buy medicine [Bangladeshi
currency]...
I: Do you have to pay him back?
M

R: No... that money could bring me more trouble!

I: What do you mean?
ED

R: He will help with the money but will give me a lecture why I am sick... if I am sick and miss
few days of work, his face [treatment towards participants] changes. He asks me to work more to
make up his losses [from not supplying scrap items].
PT

The limited access to employer support – and to families and formal services – served to
CE

encourage the street children in our sample to instead seek care from their peer networks. Interviews

showed that giving and receiving direct care from friends and acquaintances during a crisis was a regular
AC

part of life on the street and crucial to survival. When participants were experiencing a health-related

crisis, it was most often their friends who provided care, although acquaintances and the occasional

bystander might also intervene during an emergency and offer support in financial, instrumental or

other ways. The next section elaborates the ways in which peer network members were involved in the

giving and receiving of support in the face of illnesses and injuries.

4.5 Sickness Care on the Streets

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All the participants reported being in relationships with peers that involved care in times of

sickness and injury. Common types of support included treatment planning and nursing care, emotional

and instrumental support, and financial assistance.

4.5.1. Treatment Planning and Nursing Care Among Friends

Interviews showed that participants often provided and received support to and from friends in

T
response to health emergencies. About three-quarters of the participants reported helping in some way

IP
care for friends in a crisis, whether it was creating a treatment plan after assessing the symptoms and

CR
helping to seek out institutional support from government hospitals, private dispensaries, or NGOs (Non

Government Organization) with health centers. In the case of a fever or blunt injury, participants would

US
report sometimes bring the affected friend to an NGO-supported center, especially when they were
AN
conveniently located (or being brought by a friend to such a center themselves during times of illness.)

Participants also reported that they and their friends would ask a sales clerk at a drug store which
M

medicine is required for a particular illness. Since drug stores in Bangladesh sell antibiotics and most
ED

types of drugs are available without a prescription, getting medicine is not a difficult task for street

children if they have the resources to pay for them. During a crisis, typical caregiving arrangements may
PT

look like what Mintu, an 11- year old participant from Karwanbazar, received after an accident. Mintu's
CE

experiences are similar to sixteen other participants:

I: Among your friends, who helped you when you're sick?

R: Hridoy and Shohel [name of two friends] did.
AC

I: What did they do for you?

R: I had an accident. I collided with a Rickshaw in Karwanbazar crossing. The wheel ran over my
foot and my toes got broken. Hridoy and Shohel saw and came to help me. They put me on
a rickshaw and took me to the hospital [Medical College Hospital is a mile away from the site] ...
I: Who decided to take you to the hospital?
R: Them [Hridoy and Shohel]. I was dying in pain...
I: Ok, then?
R: They stayed with me and brought me back once a cast was put there... They carried me
back...

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The actions and measures described here indicate a well-coordinated peer network that is responsive to

crises that occur. The interviews revealed that friends did not seek consent from the affected youth

regarding treatment but rather took it upon themselves to provide support or set up a caregiving plan.

This and other similar events illustrate the confidence participants often place in their friends in making

critical caregiving decisions on their behalf.

T
Certain illnesses required ongoing care and support. For example, when youth were sick with

IP
acute diarrhea, they needed more intense nursing care. Informal support from friends was perceived to

CR
be a reliable source of such nursing support for over half of the participants. For example, when Ratan

was sick with severe diarrhea, he reported that his friends bought oral saline and medicine from a drug

US
store for him and took care of him for an extended period of time:
AN
R: I had this diarrhea. Oh Allah! It was terrible. After a day, I was too weak to move. I was so
weak that I thought I am dying. I did not have any energy to do anything. My friends made
saline [oral] for me. They bought me green coconut and made me lemonade. They also washed
M

my dirty clothes.
I: That's so nice! How did they manage it?
R: There were three of them- Rajon, Shafique and Sajeeb [three friends]. They nursed me
ED

by turn. One of them stayed with me.

I: What else did they do?
R: They consoled me saying that nothing had happened to me. I will be all right soon. Even they
PT

promised me that they would not let me die here. They said that they would take me to the
hospital if it is too bad. They took so much care of me that I will remember it forever. I can't
remember anybody was so kind to me [in an emotional voice].
CE

Arranging a care rotation meant each of these three friends was investing time, resources, and energy in
AC

helping Ratan. Working together they minimized their economic losses and managed to earn sufficient

money to cover treatment expenses. It is further significant that Ratan trusted both his friends’

commitment to him and their judgment about his care needs. He might have been able to go to the

nearby government hospital, but he preferred to stay with his friends, confident that they would take

him to the hospital if it became necessary.

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The examples above illustrate that many peer network ties come to support an injured person

willingly and under their own initiative. About half of the participants reported that they had offered

service or arranged care [hospitalization] for friends in the past, even when friends did not ask for such

help. Importantly, about two-thirds of the participants suggested that they would do so if needed. It

seems that friendship ties created a tacit understanding among participants to get involved in a crisis

T
without an invitation. The following conversation offers support for this conclusion:

IP
I: You mentioned that you take your friends Babu, Rasel and Sharif to a doctor when they are
sick. Do they do the same for you?

CR
R: Yes, Rasel and Sharif did it once. Me, Rasel and Sharif [friends] went to Kamlapur train
station. I got off the train before it stopped. I was running to keep my balance and was
struck with a pole. I got cut in my head and it was bleeding. Rasel took me to the dispensary. The guy

US
washed the cut and put a bandage and gave us medicine. He charged us 50 taka for that. Rasel
had 100 taka with him. He bore the cost...
I: Did you seek friends' help?
AN
R: I didn't. It happened before their eye. They won't be sitting there or leave me if I am injured. I
won't either. I know when to come to help a sick friend and I know they know it too.

About half of the participants mentioned that they would not ask friends for nursing care unless it was
M

necessary, but as has been seen, friends often provide care without a direct request. Participants
ED

mentioned an array of reasons why they hesitated to ask friends to help them through sickness. Their
PT

answers assert that they would like to use friends' services only when they are unable to manage

themselves. "...I do not like to be a burden on my friends" or "It's not a good idea to involve friends all
CE

the time..."

4.5.2 Financial Support Among Friends

AC

There was overwhelming evidence from the interviews that financial support was given and

received in response to sickness and injury. As with treatment planning and nursing, financial support

was disproportionately provided by friends rather than acquaintances. Almost all the participants

asserted that they could at least sometimes rely on their friends for financial support in these situations.

Depending on the needs and intensity of the relationships, they received loans, donations or a

combination of both. A small donation was the most common form of support a sick friend would

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receive while experiencing a minor sickness. In some cases, friends donated relatively large sums if a

child had an accident or succumbed to a major illness. Yadul, a 15-year old participant at Karwanbazar

described how his friends managed money for him after an accident. Yadul was selling fruits on the

sidewalk and had witnessed the accident.

I: Can you share with me a story about how you support your friend(s) when they get sick?
R: You know Rasel [a friend], he had an injury in his head. He fell from a truck [vegetable

T
truck] and bumped his head on the pavement. I was nearby; He was unconscious. I shouted at

IP
other friends for help and took him to the hospital. The doctor told us that he needs an x-ray.
Rasel had a little money with him. We paid the rest. Five of us, each paid 50 taka...
I: How did you collect money?

CR
R: Me and Raza [another friend] took him to the hospital. Raza came back to get money for
an x-ray. He got it from other friends. Alamin, Monsur, helped us...
I: Did you have any trouble getting funds from friends?

US
R: No, not at all. We all support each other this way...
This conversation shows evidence of an organized effort among friends to raise money for
AN
another friend in the face of injury. Rasel's injuries motivated friends to organize a successful

fund-raising drive in a relatively short time period. This event reflects behavior that is rather
M

common across sites, as over one third of the participants reported that their friendship groups
ED

acted in a similar way in response to a friend’s injury. Specifically, there were several examples

of friends promptly organizing financial support drives without questioning the amount of money
PT

needed for the treatment or the way a sick friend would spend the money that has been collected
CE

to support him.

Whereas financial support was more often given and received among friends,
AC

acquaintances did get involved in financial support in some circumstances. Specifically, in cases

when friendship groups did not have enough cash to help a sick friend in immediate need,

several interviews indicated that friends would approach less well-known acquaintances,

requesting an economic sacrifice for the affected youth. Such was the example of Ratan, a

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participant from Kamlapur, who sheds light on a friends' effort to help a sick friend by appealing

to an acquaintance.

R: One day Ashik [Ratan's friend] had fever and diarrhea. He was throwing up. He asked me for
10 taka. He said that he did not have any money to buy a meal. I did not have any money either.
I told him not to worry. I looked for a Khep [a one-time/one-trip job carrying luggage] but could
not manage one. I saw Kamal [an acquaintance of both Ashik of Ratan] managed one. I
explained him Ashik's sufferings and asked him to transfer the luggage to me so that I can give
Ashik the money. He looked at me and gave it to me. I got 20 taka from there and gave the

T
money to Ashik. Later, I managed a couple more Kheps and brought oral saline and green

IP
coconut for him.

CR
This example demonstrates the measures a friend (Ratan) may take to help a sick friend (Ashik).

In this relational dynamic, it seems likely that Kamal, who did not know Ashik well, also did not

US
have particularly strong feelings for Ashik. Yet, by transferring his Khep to Ratan (Ashik’s

friend who was also an acquaintance to Kamal), Kamal gave away his Khep, making an
AN
economic sacrifice to provide indirect support to an acquaintance that he hardly knew. The weak
M

tie relationship between Kamal and Ratan might suggest that Kamal would have limited

motivation to provide such support, according to conventional notions of weak tie relationships
ED

(e.g., Granovetter, 1973;1983). Perhaps, however, the state of a sick acquaintance, whose plight
PT

street children can identify with given their similar circumstances and needs, prompted Kamal's

decision to transfer the Khep. This kind of indirect support available within some street
CE

children’s networks is worth noting, given the competition among them over limited number of
AC

Kheps and other obstacles to being economically successful as a porter at the train station. It

seems that under some circumstances, especially those that highlight a fellow street child’s

suffering, bonds of solidarity and a recognition of mutual dependence may motivate support

among acquaintances who would otherwise be in competition with one another.

Direct repayment of the money spent by friends for the treatment and post-treatment care

was seldom expected, unless the amount was significant. Over 60% of participants suggested

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that they did not expect to pay back the money that they had received from friends during

sickness. In contrast, acquaintances who provided direct financial support did typically expect to

get their loan back once a sick or injured youth recovered. The norms among friends that

discourage financial reimbursement may develop from the tacit understanding that mutual

support is necessary for street children’s survival. The support exchanged among friends may be

T
an important glue that helps to maintain these highly instrumental friendship bonds. By not

IP
demanding a return, they may engender trust across ties, helping to sustain relationships and

CR
facilitate coping. One participant explains that if anyone requires payback for the money spent

for a friend's treatment he "...can't be a good friend." As elaborated in the discussion, these

US
examples of peer support without expectation of direct repayment suggest that a system of
AN
generalized reciprocity may have governed support relationships among many youth.

4.5.3 Role of Acquaintances in Crisis Care

M

Interviews revealed that acquaintances could also provide aid to street children, as was evident
ED

with the case of Kamal discussed above. This was most frequently described as occurring in response to

a crisis, where immediate attention was needed. Asad, a thirteen-year old participant from Karwanbazar
PT

shared a story about how he helped two acquaintances in a crisis. As Asad reported, he was selling
CE

newspapers when he saw two boys crossing the road together. The two boys were running to cut

through the traffic but a motorbike hit one and the other fell under a three-wheeler. Seeing the
AC

accident, Asad cried to his nearby friends that they should inform the injured boys’ friends of the

accident. Asad reported that he then ran to the two boys and found one was seriously injured and the

other had some minor bruises. By then, two friends of the seriously injured child arrived on the scene.

Asad and two other boys (friends of the injured) took the injured boy to the hospital. He stayed with

him, bought him medicine, and subsequently supported him in meals and finances although he had not

been a friend prior to the accident. It was unclear from the interview what led Asad to continue

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supporting the boy even after his own friends came to his aid. As discussed further below, friendships

sometimes developed between children who had previously been weakly connected after one child

responded to the crisis of the other.

In other cases, support from acquaintances was not as extensive. But in the midst of a crisis,

even small acts of support from acquaintances could result in consequential support when summed

T
across their peer ties. The example of Babu illustrates this point. After Babu, an 11-year boy from

IP
Kamlapur, broke his arms and a leg falling from a moving train, he was dependent on a network of

CR
friends, acquaintances, and even strangers for most of his needs. His friends supported him with food

and money. Babu could not afford a crutch and therefore relied on a wide array of individuals to move

US
him around the train station platforms. According to Babu, he was hardly ever rejected by any of his
AN
peers when he requested help moving from one place to other. It is possible that Babu received this

frequent help from acquaintances and strangers because of the extremity of his disability. Perhaps the
M

helplessness of his physical state attracted the sympathy of a wider network of individuals than would
ED

be possible for peers perceived as able to contribute more toward their own survival.
PT

4.6 The “Price” of Caregiving

As evident above, caregiving on the street requires sacrifices of time, energy, and resources.
CE

Struggling to manage one’s own life and taking responsibilities for a sick friend can be overwhelming. As

shown above, most all street children that were interviewed reported that they sacrificed their own
AC

economically productive time while nursing a sick or injured friend to health. About 40% of participants

reported that the caregiving supports they provided created difficulties in managing their work and

other responsibilities. Jumman, a 14-year old participant from Karwanbazar, commented:

I: You know, the difficulty is, uh, I work here. I need to sell at least 75 newspapers to manage
my day's income. If anything disrupts my work, it is difficult for me to manage the day.
R: Had you [your work] been interrupted by anything?
I: Yes, I was sick and could not work. [Then] Arif [a coworker who sells newspaper] got into an
accident. We took him to the hospital. I could not sell my quota of newspaper. It was a bad day.

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 ACCEPTED MANUSCRIPT

I made only 30 taka. I had to give Arif 20 taka for his treatment and I had only 10 taka to cover
the day. Kajol bhai [newspaper distributor] did not like this.
I: If you face all these problems, why do you help your friend then?
R: They are my friends; I need to help them out. If I don't help my Dosto [Friend], they won't
come either.

The conversation with Jumman offers evidence of his sacrifice for a friend (i.e., leaving work to take him

to the hospital and sharing his day’s meager earnings), but also the instrumental nature of the

T
relationship (i.e., “If I don’t help my Dosto, they won’t come either.”) and the consequences he faced for

IP
his actions (i.e., his employer’s disapproval and loss of income.) It appears that Jumman is less worried

CR
about his immediate economic losses than he is with maintaining the reciprocal relationship between

him and his friend and his relationship with his employer, who he later reports could fire him for taking

US
time to support his friend. The employer had not fired him yet, but a similar event could force him to
AN
quit the job. Five other participants reported similar or more intense conflicts with their employer when

they were absent from work while looking after a sick friend.
M

All participants had limited income to support their caregiving efforts. However, girls’ average
ED

median income was even lower than that of boys. The median income of the girls in the sample was

about 50 taka (65 cents), suggesting that their ability to provide economically to respond to health crises
PT

was especially limited. Considering minimum daily food expenses to be 50 taka, very few girls would
CE

have surplus income to help support a friend’s treatment without burden. The interviews suggested

that some girls resorted to their [boy]friends for financial help for their own health needs and that of
AC

their friends. Given the limited power that most girls likely had in these relationships, any pressure for

financial help could bring undesirable outcomes. For example, Nupur begs on the street to make a living

in Kamlapur and often relies on her [boy]friend's support. On one occasion, when her best girlfriend was

sick with fever and diarrhea, she spent the little she had made from begging to help her friend and

asked her [boy]friend for additional money. Nupur's boyfriend did not like the idea that Nupur spent her

money on a friend, they had an argument and her [boy]friend got upset and verbally abused her. As

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Nupur described the situation, her protests made her [boy]friend angrier and at one point Nupur's

[boy]friend physically assaulted her. In addition to Nupur, three other girls reported difficulties in

helping friends who suffered an injury or health crisis. Not all of them were able to rely on other friends

to help the friend in need. One girl expressed her remorse this way: "... I want to help my friends but I

myself struggle to manage food. How can I spare?"

T
As the example of Nupur illustrates, there are non-monetary risks that children often assumed

IP
in order to help sick friends. In six other instances, participants reported that helping a sick friend

CR
jeopardized their own safety. Sharif's story is an example of the high risks that street children sometimes

face while helping a friend experiencing a health crisis. Sharif was friends with Babu, the boy who had a

US
cast on his leg and arms mentioned above. As Sharif reports it, the trouble started when a "Dhora Gari,”
AN
a vehicle with officials who arrested and took away vagrants to a correctional facility, came to arrest

street children from Kamlapur. The appearance of a "Dhora Gari" causes a real panic for the participant,
M

who had to scamper to hide and avoid arrest. Since Babu could not move alone, it was left to Sharif to
ED

help him try to escape. When the officials were close by, Sharif panicked and pushed Babu into a train

that was about to leave the station. He then jumped to catch the door handle. Sharif suggests:
PT

R: Yea Allah, even if I remember [the incident] that day, I panic. I saw the guys [officials] about
to catch us. I pushed Babu but he could not move. Half of his body was dangling outside the
CE

train. I prevented his fall blocking him from behind while I was hanging myself. I said, "Babu, if
you can't push yourself both of us will be under the train. The train was speeding up. A vendor
[who sells food or other items on the train] saw and pulled him inside. My hands were slippery; I
could just slip under the train...
AC

The above incident is a striking example of how friends risk their own safety when helping a sick friend.

For Sharif, Babu's safe escape from the Dhora Gari was as important as his own. Even though similar

examples are not frequent, this example shows the potential risks that participants confront to help

friends in need. In Sharif’s case, he suggests his actions toward his friend Babu would have been similar

for an acquaintance or a stranger, given his “soft heart” and his willingness to help “anyone in need of

support.”

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Although there were many examples of participants helping one another to survive health-

related crises, it is important not to romanticize the support networks of street children in the sample.

At times, social relationships became strained and conflictual. As noted earlier, some girls faced abuse

from [boy]friends when they disapproved of the manner in which the girls used financial support.

Conflict also occurred when sick and injured street children did not follow the advice of their friends and

T
acquaintances who supported them. As such, non-compliance within peer network members acted as a

IP
means of social control that may have regulated the street behavior of youth. The interviews suggested

CR
that it was the peers who provided support who were generally the ones making decisions about what

medical interventions she or he should undertake. In eight cases, interviews revealed that

US
noncompliance with friends' decisions resulted in tension and invited criticism from other peers in the
AN
social network. Bablu, a 15-year old at Sadarghat, is a case in point. He cut his toe when he stepped on a

piece of broken glass. One of his friends helped him stop the bleeding by putting on a bandage. Babul's
M

friend suggested that he wash the bruise with Savlon [an anti-septic liquid] to prevent an infection.
ED

Babul ignored the advice and his foot became infected. With pain and fever, Bablu again sought his

friend's input. The friend was angry that his earlier suggestion was ignored. He shared his displeasure
PT

with other friends, who rebuked Bablu for not paying attention to the first suggestion. One friend
CE

derided him saying, "...you're [Bablu] a Pundit, you do not want to listen to other. Now you pay for it".

The foot was eventually treated when another friend accompanied Bablu to a nearby hospital.
AC

4.7 Caregiving and Change in Relational Dynamics

The findings of this study suggest that caregiving and crisis support can strengthen relationships

between children on the street – in some cases promoting “acquaintances” to “friends.” However, it can

also cast doubt on a friend’s commitment and may relegate a friend to an acquaintance when a friend is

perceived as not sufficiently contributing to the relationships or when an act of support is not

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sufficiently appreciated or advice not followed. Interviews confirmed such changes in slightly over half

of the cases in both directions.

There were several examples of caregiving support seeming to foster a friendship relationship

between two people who had previously had a relatively weak connection, or in some cases had been

strangers. For example, Tuhin reported becoming a friend of Jummon because of the support he

T
provided him. He states:

IP
I: What do you do with Tuhin [a close friend]?
R: I do everything for him. He is a good friend. You know, he was not like this. He used to

CR
mingle with another group.
I: How did you get close then?
R: I got an accident and broke my arm. He took me to the hospital and spent 300 taka... I could

US
not do anything with my broken arm. He helped me feed... he brought me water, he helped me
bath. I could not work those days. He gave me money. He told me, 'don't worry, I will be with
you'. So many other things he did for me.
AN
I: If he is not a good friend, why did he do it for you?
R: I don't know. He was there when I got into the accident. I didn't ask why he did so much for
him. But I promise I will do more than what he did for me.
M

In another instance, a participant from Sadarghat fell into the river from an anchored launch
ED

[ferryboat] while he tried to jump into an incoming launch. He did not know how to swim and was

drowning in the river. Seeing this, a stranger youth jumped into the river and rescued him. Since the
PT

incident, the rescuer was described as a Janer dosto [a very close friend]. In another example, one
CE

participant saved an acquaintance while both of them were selling newspaper in Karwanbazar. The boys

were in the middle of the road in an effort to sell papers to passengers in a bus that was stuck in a traffic
AC

jam. The traffic moved suddenly and there was a big rush to proceed. Seeing that his coworker was

about to collide with an oncoming motorbike, the other boy pushed him aside. He saved his coworker

but could not keep his own balance and bumped into a rickshaw. He injured his leg and was taken to a

local dispensary. The saved boy bore treatment expenses and fed the injured boy with a rich diet to

"recover the blood that was lost during the accident." This accident and subsequent events set their

relationships on a fast course and they reported becoming Janer dosto to each other. In both of these

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instances, one participant risked his safety to support the other. Emotions ran high creating conditions

that were ripe for friendships to develop.

As noted above, not all relationships among peers improved because of the caregiving

support that was provided to one another. In some cases, street children doubted a friend’s

commitments because he was judged to be selfish – taking the help of others but not providing it

T
himself. For example, Biplob felt that one of his friends deliberately avoided him when he was

IP
sick and would not provide him financial support when he needed it. Biplob shares his

CR
experiences:

I: Ok, ok. You said that Amir is your friend but then you said he is no more a friend. How long do

US
you know him? What happened between you guys?
R: I know him for about a year. We used to be good friends... He is a traitor. I do not mingle
with him much...
AN
I: Did it happen that you helped him or seek help from him?
R: Amir did not help me, I helped him...
R: He never returned any favor. I was sick and he did not come to even see me. I thought he
M

might be busy. But I saw him playing with other children. If you pretend to be a friend but do
not visit a sick friend, what type of friend you're? When I asked him about this he argued with me...
One day I asked him for a loan as I was having difficulties. He said ‘no’ to my request... His
ED

self-serving stories are countless...

I: Did you share this with others?
R: Yes, they told me that he did the same with others. He is a very selfish person.
PT

Apparently, Biplob expected that Amir would visit him while he was sick but Amir did not come forward
CE

and apparently socialized with friends instead of helping Biplob. Biplob was disappointed and this

created tension in their relationship. This tension built further as Biplob observed Amir's selfishness and
AC

checked in with other friends about their own experiences with his lack of reliable support. According to

Biplob, Amir continued his selfish acts and did not change his non-supportive behaviors, seriously

compromising Amir's relationship with Biplob. It is unclear from the interview whether Amir’s “selfish”

behavior resulted in sanctioning from the peer network or even exclusion from the generalized support

exchanges that benefited many street children.

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In some cases, friendships became tenuous (and relationships relegated to that of

“acquaintance”) as a result of demands for immediate repayment of loans given during sickness.

As noted earlier, many friends reported not expecting repayment immediately, but in some cases,

a friend did ask or even demand that a loan be repayed. It is possible that demands to pay a

“sickness loan” symbolized a break in trust and questioned the emotional and instrumental

T
commitment to a friend during a vulnerable time. Murad from Sadarghat borrowed a relatively

IP
large amount of money [100 taka, $1.30] from a friend while he was sick. He was given a

CR
reminder to pay back the full amount as soon as he got well. Murad reported that he asked for

time but the lender was reluctant to wait for repayment. This increased tension between them and

US
a fight broke out over the conditions of the loan. Their common friends negotiated an agreement
AN
that Murad would pay half of the loan immediately and pay back the rest in few weeks. Given

Murad’s financial situation, to pay back half of the loan, he had to borrow again from another
M

friend. Murad eventually paid back both parties but the tension between the two boys remained
ED

and Murad reported that they were no longer friends. In fact, during the interview session, Murad

justified his decision to break off all ties with the lender saying: “Oi Halar Put [a derogatory
PT

slang] is a traitor... can't be my friend. Otherwise, he would not treat me like the way he did. He
CE

forgot what I did for him.” It seems from this example that Murad believed that friends should

maintain a more generalized notion of reciprocal support, rather than expecting a direct loan
AC

repayment. Of course without an interview with the lender in this example, it is not possible to

understand the situation from his perspective.

5. Discussion

Street children face daunting challenges related to their needs for food, shelter, and

healthcare. This study suggests that they develop a range of responses to encounter these

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challenges and most all of them involve their street network peers. Despite the often horrific

circumstances of everyday existence on the street, peer networks can make life bearable and

even sometimes enjoyable for them. The current study extends our knowledge of the social

networks of street children by demonstrating their critical role in helping fellow street children

respond to sickness and health care crises.

T
The findings demonstrated high incidents of sicknesses and injuries among street children

IP
as all of the participants reported visiting at least one of the healthcare institutions within the last

CR
six months for a health-related matter. The causes of their visits varied from minor accidents to

serious injuries and health problems. These visits to a medical center or hospital indicate that

US
street children were accessing some available health services, as well as confirming that they are
AN
especially vulnerable to sickness and injury (Uddin, Koehlmoos, Ashraf, Khan, Saha, & Hossain,

2009; Greksa et al., 2007). The use of formal services often were orchestrated and paid for by
M

friends, but sometimes also by acquaintances with whom they were less familiar. These peer
ED

networks provided substantial caregiving support to street children suffering from health crises,

offering emotional support, instrumental help, and even sharing daily earnings.
PT

The findings on the incidence of health crises in this sample are in accordance with
CE

earlier studies suggesting that street children are prone to occupational injuries more than older

workers (Saliman, 2004). Pinzon-Rondon and her colleagues (2009) conducted a cross-sectional
AC

study with a relatively large sample of young street workers in four Latin American cities. They

found high incidents of injuries among participants, but the prevalence of injuries in the current

sample was even higher than what Pinzon-Rondon and colleagues found. One possible reason is

that this study analyzed data from a sample of exclusively street-dwelling children whereas

Pinzon-Rondon and her colleagues used a mixed sample of street-dwelling and non-street-

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dwelling youth. Also, the participants in the current study were on the streets for longer periods

of time than the other study; thus, the risk of injury was likely to be higher for them. Moreover,

Dhaka city – the site of this study – is considered to be the second worst livable city in the world,

particularly with its high incidents of traffic accidents. A considerable number of these accidents

involve child pedestrians (Ahsan, 2012). Since street children spend most of their time on either

T
the street or sidewalk, the chances of accidental injury is likely to be especially high for them.

IP
Our findings revealed that support from network members was the primary means

CR
through which street children managed injury and sickness-related crises on the street. Tangible

support came in the form of food and money and intangible support came in the forms of

US
nursing, emotional comfort, and companionship. Social network support in times of need is a
AN
common survival strategy of many low-income groups (Heflin & Pattillo, 2006; Henly,

Danziger, and Offer, 2005; Edin & Lein, 1997; Stack, 1974; Uehara, 1990). Support exchanges
M

among street children, especially food exchanges, have also been observed in studies of street
ED

children. Kovats-Bernat (2006), in his ethnography with street youth in Haiti, found that youth in

his sample cooperated with each other to maintain an adequate supply of food by pooling daily
PT

resources that guaranteed participants a daily meal. Our study adds that exchange of food is
CE

almost a ritual among the participants who are in health crisis. When a meal was offered during

sickness, there was seldom an expectation of return. In the financial realm, we found that during
AC

sickness or an accidental crisis, a small financial donation was the most common form of support

a sick friend could expect from friends, and sometimes also acquaintances. In some cases, the

donation amount could be relatively large if an injury was serious and the injured child needed

extra finances to cover treatment expenses. Friends took upon themselves most of the financial

burdens if a sick youth was unable to manage treatment costs alone.

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 ACCEPTED MANUSCRIPT

This is not to say that the caregiving that street children provided to others on the street did not

affect their own wellbeing in negative ways. They incurred hardship due to sharing already meager

earnings and missing work that could upset relationships with employers in a highly competitive labor

environment. In rare instances, caregiving roles also endangered children’s physical safety. Finally, in

some cases, a friend could lose his valuable friendship with another youth because of unmet caregiving

T
expectations. On the other hand, the demands of caregiving could also strengthen a friendship

IP
relationship over time.

CR
As Uehara (1990) noted, the support systems that operate within communities of extreme

scarcity represent a continuum of exchange relationships. Heterogeneity in network relationships

US
was also observed in the current study. In some cases, youth seemed to act out of an ethic of
AN
care, suggesting a moral norm of helping others in need regardless of repayment possibilities

(Gouldner, 1960; Uehara 1995). In other cases, the support that youth extended suggested that
M

peers were embedded in a system of mutual exchange that functioned out of survival more than
ED

because of a broader ethic of care. A form of generalized reciprocity may have been assumed

among friends, whereby expectations for repayment were not immediate or direct (Uehara,
PT

1990), but where there existed a tacit understanding that mutual support was essential to survival
CE

on the street (Stack, 1974). In other words, at any point in time, a one-way offer of support may

have been acceptable because it was understood in the context of a relationship in which friends
AC

were routinely helping friends during times of need. The peer network in these cases may have

functioned as a “social support bank” (Antonucci, 2001) whereby offers of support were paid in

and withdrawn when needed, albeit with inexact accounting that was likely subject to the actor’s

interpretation. Expectations of reciprocity reported by youth did not always reflect such a time-

delayed process, however. Restricted exchange expectations were also observed in the sample. In

these cases, we found that repayment of support, especially financial assistance, was expected,

36
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and that the price of non-compliance (not repaying a loan within an agreed upon timeframe)

could mean the loss of future support and the eventual breakdown of a friendship relationship.

What does this study reveal about the process of caregiving available to street children in

response to a health-related crisis? To be sure, the interviews indicate that street children receive

and give several types of support to one another in the face of illness and injury. But more than

T
that, the interviews elucidate understanding regarding street children’s caregiving behavior and

IP
how relationships develop (and in some cases break apart) through mutual support in response to

CR
health crises. About three quarters of the participants reported participating in at least one event –

from planning to implementation – of sickness and injury care for friends. Friends consulted

US
among themselves to find the right treatment, accompanied the sick to health care professionals,
AN
bought drugs from the drugstore and arranged rotating care for the sick. This was in addition to

arranging and providing nourishment and emotional support. In case of a serious injury, friends
M

intervened to arrange hospital care for the injured youth.

ED

Strikingly similar findings regarding peer network roles in health care were reported by

Mizen and Ofosu-Kusi (2011) in their three year ethnography of street children in Accra, Ghana.
PT

They found that social relationships among friends of young street children were critical for
CE

surviving illness and injury. Friends managed food and water, ministered care, ran errands,

procured herbal remedies or pharmaceutical drugs for the sick or injured. Similar to Mizen and
AC

Ofosu-Kusi, the current study found that friendship ties played a key role in responding to crises

of illness and injury. However, in contrast to Mizen and Ofosu-Kusi, the current study also

revealed that at times acquaintances and strangers helped during a crisis as well. In some

instances, strangers’ involvements were extensive and they accompanied the injured to the

hospital, sponsored treatment costs, nursed the injured and took care of basic post-treatment

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needs. Conticini (2004) suggests that a street child may build his or her identity as part of a

“street community” rather than an individual actor. This “street community” identity may

contribute to the willingness of youth to share resources beyond a friendship group to other

youth who are part of the larger street culture. Given the extreme disadvantage and hardship of

street life, “going it alone” is likely to be an unsuccessful approach to getting by. Even amidst

T
heavy competition for scarce resources, it may be in the best interests of street children to

IP
support one another as a means of facilitating survival. Thus, irrespective of the possibility that

CR
street children take on a communal or collective identity, there may be norms that govern

supportive behavior on the street that exist as a mechanism of control and to foster survival under

extreme circumstances.
US
AN
Implications for Practice

Findings from this study reveal the poverty, hardship, and danger that characterize the
M

everyday reality of street children’s existence. Street children may benefit from a wide range of
ED

supports and services to meet a broad spectrum of needs—from financial security, housing,

education, health services, family supports, recreation, and socio-emotional development. This
PT

study also reveals the multiple ways in which children surviving on the streets support one
CE

another through the daily struggles and economic and health crises of their difficult lives. We

suspect that interventions targeted toward street children would be most successful if they were
AC

to build on children’s coping strategies – capitalizing on youths’ capabilities and those of their

peers – and avoiding a ‘victim discourse,’ which can label children as helpless recipients of aid

(Fahmi, 2007). Programs that are “resilience promoting,” that is, account for children’s strengths

and assets (Conticinni & Hulme, 2006) may have the greatest chance of delivering positive

results. An approach that does not build on children’s strategies for survival – which almost

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always include peer relationships – could inadvertently interrupt key adaptive arrangements (e.g.

support networks, economic livelihoods) that appear to be critical responses to the extreme

poverty, dislocation, health crises and abuses children on the street experience and may continue

to experience even as they receive services. Importantly, by emphasizing the strengths of peer

relationships, we are not suggesting that informal support networks are sufficient on their own.

T
To substantially ameliorate their circumstances would require significant outside intervention.

IP
We argue, however, that any intervention for street children, whether its focus is family

CR
reintegration, a group-based or independent living arrangement, an employment or education

program, or the delivery of health care services to respond to health crises as is the primary

US
concern of this study, may benefit from engaging children and their networks of support as active
AN
agents in the service plan.

In our study, peers were sources of support, safety, and caregiving, but they also
M

represented risk and competition for resources. Not all street children in this study appeared to
ED

have access to the same degree or type of peer support, and at times there was conflict among

peers. Thus, as services bring peer networks into the treatment process it will be important to
PT

identify these relational influences – including both positive and negative sources of support. For
CE

example, programs targeted at individual children might explore the specific strengths and risks

within a child’s immediate environment, and develop an individual treatment plan that responds
AC

to the immediate physical and social environmental dangers facing a child, as well as relational

sources of support from peers (and in some cases adults) that can be integrated into or

supplement formal services.

Play and recreation is a critical aspect of childhood, and we found this to be true for street

children in our study as well. Interventions targeting groups of children on the street can engage

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youth in recreational activities as a mode of nurturing existing relationships and exploring

opportunities for change. One such program is Narrative Theatre Intervention where groups of

children (mostly friends and close associates) are encouraged to open up and share their

experiences through storytelling, drama, and poetry (Nyawasha & Chipunza, 2012). This

program is designed to foster communication, build trust, increase knowledge and make children

T
aware of their rights through group-based activities that recognize existing peer relationships.

IP
Overall, findings from this study suggest that the social networks of street children can be

CR
leveraged to support a broad range of service efforts including harm-reduction interventions,

referral services, peer training, education, and play (Karabanow and Clement, 2004). The

US
findings lend credence to an approach to service delivery that reaches beyond the individual
AN
child to the social networks that structure and guide street life for many of these children.
M
ED
PT
CE
AC

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