Critical perspectives from Latin American social medicine

The Social Determinants of Health Model7, while influential, often lacks the depth to address the deep-seated historical and structural issues specific to Latin America. It tends to focus on immediate health determinants like socioeconomic status, education and access to healthcare without fully integrating the historical context of colonisation, economic exploitation and gender-based oppression. In contrast, the Social Determination of Health Theory8, based on Latin-American critical social medicine, emphasises understanding these root causes and their persistent impacts on health and social conditions. By considering the long-term effects of socio-historical processes, this model provides a more comprehensive framework for addressing the systemic inequities faced by SWC.

Coloniality, as a persistent logic of power9 10, continues to marginalise indigenous and Afro-descendant populations, imposing a Eurocentric culture and social hierarchies that negatively impact the epistemology and cultural heritage of these groups. In many Latin American countries, indigenous children are forced to work on the streets due to the lack of government programmes that support their communities, respect their cosmovision and recognise their traditional modes of socio-political organisation and economy, including practices such as handicraft work or barter. Heteropatriarchy, as María Lugones11 highlights, perpetuates the subordination of indigenous and Afro-descendant women, placing girls in street situations at higher risk of sexual exploitation and gender-based violence. Additionally, humanitarian crises and increased migration in many countries leave these girls especially vulnerable to exploitation in border areas.

Neoliberal capitalism, as explained by theorists such as David Harvey12 and through the lens of the Global South by Immanuel Wallerstein13, Anibal Quijano9 and Arturo Escobar14, relies on the exploitation of peripheral regions, perpetuating poverty, inequalities and a chronic lack of opportunities. Policies such as labour market deregulation and the privatisation of basic services not only exacerbate these inequalities but also force many children to work to contribute to family’s sustenance. The resulting expansion of the informal economy, coupled with a lack of state protection, further exposes these children to exploitation by armed groups and organised crime. In these contexts, SWC often become targets for recruitment or coercion, trapped in cycles of violence and poverty that are difficult to escape.

These systems of coloniality, heteropatriarchy and capitalism are deeply interconnected and interdependent, collectively contribute to structural violence, manifesting in the gap between human potential and real-living conditions. An additional layer of complexity is added by the way governments in the region have addressed the drug problem, often through prohibitionist policies that further marginalise SWC. Prohibitionist approaches have propagated the stigma against street dwellers and allowed therapeutic communities, many with charitable and religious orientations, to control the provision of rehabilitation and social assistance services. This has exacerbated the vulnerabilisation of these children, limiting their opportunities for rehabilitation and social reintegration15 16. Incorporating this dimension is essential for understanding the full scope of challenges faced by SWC and the necessary interventions.

Shaping street-working children through predominant paradigms

The way a problem is represented in social and health public policy discourses plays a crucial role in shaping the reality of that problem. The Affective Interstice Theory17, in dialogue with the Social Determination Health Theory, integrates semiotic, material and affective dimensions, highlighting how such discourses generates a circulation of emotions and material realities that shape subjectivities, identities and capacities for agency and resistance, either limiting or expanding possibilities for transformation. This alternative public policy analysis approach provides a deeper analysis of how power, through affects and materialities, reproduce social and health realities, particularly in contexts of marginalisation. The hegemonic representation of the problem in public policies directed at SWC not only reflects but also perpetuates interventions, social attitudes and subjectivities that exacerbate their vulnerabilisation. The following are the predominant paradigms; while the first four fail to address the socio-historical determination perpetuating the SWC problem, the last two offer counter-hegemonic alternatives.

In addition to being derived from the conceptualisation of the Affective Interstice Theory’s analytical dimensions17, these paradigms are further informed by my involvement as a volunteer with La Esquina Redonda 18, where I have participated in their efforts with street dwellers. The ethnographic insights gained from these experiences offer practical perspectives that validate and enrich these theoretical views. Moreover, these paradigms are supported not only by reviews of authors in critical thinking but also by research and comparative analyses conducted in Latin American countries, especially in Brazil and Colombia, highlighting the diversity and heterogeneity of regional contexts. It is important to recognise that these paradigms do not manifest uniformly; they are shaped by specific national contexts that determine how SWC are perceived and treated.

Control and Normalisation Paradigm views SWC as social anomalies requiring control and normalisation. Public policies under this framework typically focus on policing and removing children from public spaces, portraying them as threats to social order. Michel Foucault’s theory of biopolitics and discipline19 provides a foundational understanding of how social institutions exert control over populations, including SWC. For instance, De Carvalho20 illustrates how public health policies in Brazil have historically been used as tools for social control, particularly in the criminalisation of poverty and the marginalisation of vulnerable populations. Aligns with Foucault’s notions of surveillance, discipline and punishment, this approach effectively criminalises SWC existence, perpetuating societal fears and justifying coercive interventions. The circulating emotions of fear and rejection further deepen their marginalisation and exclusion. By treating these children as threats, this paradigm not only validates harsh measures but also entrenches a cycle of fear and segregation, making it increasingly difficult to implement more compassionate and effective solutions.

Hygienic-Sanitary Paradigm views SWC as public health hazards that need to be sanitised, prioritising urban cleanliness over the well-being of the children. Interventions often include forced relocations and mandatory health checks, which stigmatise these children as contaminants, create emotional barriers with the community and reinforce their status as outsiders, deepening their marginalisation. For instance, in Brazil, public health policies have historically prioritised those actions20. Susan Sontag’s Illness as Metaphor 21 offers a critical lens to understand how metaphors of disease and cleanliness are applied to marginalised populations like SWC, reinforcing their social exclusion. The emotional distancing created by the ‘sanitising’ public space efforts perpetuates neglect and segregation, making it increasingly difficult to pursue more inclusive and care-based approaches.

Charitable Paradigm positions SWC as passive recipients of charity, focusing on immediate relief through temporary shelters and food drives while neglecting the underlying structural issues that perpetuate their situation. In Latin America, public policies have often relied on charitable approaches, which, as discussed by Atun et al. 22, typically reinforce dependecy rather than addressing the underlying structural causes of inequality. This approach fosters feelings of pity rather than empowerment, perpetuating a cycle where children are seen as perpetual dependents rather than active agents of change. Paulo Freire’s Pedagogy of the Oppressed 23 critically examines the power dynamics inherent in charity, arguing that it can unintentionally reinforce dependency rather than fostering true empowerment—a point especially relevant to the long-term effects of charitable interventions on SWC. Pity does little to alter the material conditions of these children’s lives, further entrenching their dependency.

Medicalised-Psychiatric Paradigm pathologises SWC behaviour, viewing their condition as a medical issue requiring treatment. By focusing on individual psychopathology, policies under this paradigm often involve psychiatric evaluations and medication, overlooking the social determination that lead children to street work. In Latin America, neoliberal health reforms, particularly in Colombia, have furthered the medicalisation of social issues, treating individuals as patients in need of fixing rather than addressing the socio-economic challenges they face24. Ervin Goffman’s critique in Asylums 25 is relevant here, as it explores how psychiatric institutions dehumanise individuals by reducing them to their pathologies—a process similarly experienced by SWC, especially those who are drug users.

Economic-Survival Paradigm views street work as a rational and necessary means of survival for children in dire economic circumstances. As discussed earlier, neoliberal reforms in Latin America have exacerbated economic inequalities24, pushing many children into street work as a means of survival. Amid poverty and lack of opportunities, emotions of desperation and fear drive children to the streets. However, facing these challenges, some children and families demonstrate resourcefulness as they organise to improve their conditions. Recognising that this alternative does not imply endorsing any form of labour exploitation or forced labour, the Latin American movement of working children and adolescents, MOLACNATS26, engages in collective actions such as forming cooperatives, advocating for labour rights and creating educational workshops that emphasise the value of their work and their rights as workers. These efforts aim not only to improve their economic situation but also to cultivate a sense of pride and agency among the children. Nancy Fraser’s analysis of social justice and economic redistribution27 provides a theoretical framework that aligns with these practical efforts and emphasises the need for systemic changes that address the root causes of economic inequality. Policies under this paradigm should focus on creating economic opportunities for families, ensuring access to education and providing social support systems that offer viable alternatives to street work. Additionally, such policies should recognise and support the self-organised efforts of these children and their families, while striving to reduce the economic pressures that drive them to the streets.

Rights-Based Paradigm emphasises the rights of children as active participants in their own lives and communities, challenging traditional narratives of victimisation and dependency. Policies within this framework are grounded in the Convention on the Rights of the Child28 and prioritise health, education and participation in decision-making processes, since recognised children not merely as beneficiaries of aid, but as active agents capable of shaping their own futures. This approach aligns with broader trends in Latin American public policies that are increasingly focusing on equity and inclusion, as highlighted by Atun et al.²² in their discussion of health system reforms aimed at addressing social inequalities. This is particularly relevant when addressing the impact of prohibitionist drug policies on SWC. Unlike conventional methods, a rights-based approach would integrate harm reduction strategies, art-based interventions and non-judgemental methodologies, focusing on minimising the negative effects of substance use without further stigmatising or marginalising these children18. By promoting their meaningful inclusion and participation in society, this approach helps mitigate vulnerabilities and supports the rehabilitation and social reintegration of SWC.