Children as biological sufferers? The paradox of international medical aid for homeless children in Cairo

Introduction: Lice treatment, psycho-pharmaceuticals, and reluctant children

It was a breezy February afternoon in Cairo when I first met Nada, a 10-year-old homeless girl who spent her days in a French-funded non-governmental organization (NGO) and children’s shelter where I was conducting ethnographic fieldwork. ¹ This NGO, which I will hereafter call Children’s Care International (CCI), provides rights-based medical humanitarian aid to vulnerable women and children in over 70 countries today. I was in the shelter’s courtyard conversing with Amira, a 26-year-old volunteer worker, when we noticed a sudden burst of commotion coming from a group of children who were playing nearby. Nada suddenly snuck up behind me, wrapped her arms around my waist, and buried her face in the small of back. She let out a desperate plea: “La mish ayza!” (No I don’t want it!). At the other end of the courtyard, Sally, the shelter’s matriarch, was rounding up children near a plastic chair. Her hands were sporting blue surgical gloves and a large bottle of a liquid lice medication. Young children bolted past me into the children’s library to hide, while older boys surrounded Sally in a playful embrace. In typical Cairene masculine fashion, they began teasing her with a mixture of clever jokes and negotiations about lice medication: “La dourik! Inty ayzā!” (No it is your turn! You need it!).

Gesturing over to Sally’s chair, Amira explained that this was how adfāl al shawāri’ (street children) received mandatory lice treatment, one of several routine healthcare interventions performed on all 30 of the children at this shelter. Health care for adfāl al shawāri’ was framed in CCI policy as compassionate care extended toward homeless children. Training manuals and pamphlets described lice treatment and other biomedical interventions as a fundamental “right” of the child, as a means to human dignity, and as integral to the development of the person. ²

But as the opening vignette of this article suggests, lice medication is a painful, dreaded intervention for children. It stings and lingers intensely on the child’s scalp long after its application. In addition, its scent is sharp and medicinal. Even Sally, who administered the treatments, complained about feeling dizzy (dukht) from inhaling the chemical odor. Because of this physical discomfort, children resisted lice treatments even as they had to succumb to them. When Amira eventually pried Nada’s arms from my waist, I observed the way in which she endured the procedure, with face contorted and eyes firmly shut. In an attempt to offer some words of encouragement, I inched my way closer to Nada and watched as Sally’s swift hands parted section after section of Nada’s curly brown hair before dousing the scalp with liquid. When she finished, Sally signaled to Nada that the task was complete and she was finally free to go. Jumping off the chair, Nada dashed into the library where other children had congregated. In defiance, she yelled the entire way, patting her medicated scalp with both arms overhead.

Lice treatment was not the only form of biomedical care children at CCI openly resisted. They were also subjected to mandatory psychiatric examinations, which for some led to supervised pharmaceuticalization. CCI provided psychiatry in an effort to rehabilitate the most “traumatized” and “unstable” homeless children via biomedical drug therapy. ³ For example, Amir, a tall and slim 14-year-old boy who lived at the shelter and underwent psychiatric care, admitted to me one day that he never enjoyed talking to Dr Mona, the NGO’s paid child psychiatrist. Moreover, he stopped taking his prescribed Tegretol (a mild mood stabilizer) each time he left the shelter to reengage in informal labor on the streets. When I asked Amir why he stopped taking the free medication if it were meant to help him, he casually responded that he does not like it when people “govern him” (yihakumu fiyya). For Amir, therefore, pharmaceuticalization represented a loss of freedom and an affront to personal agency. It did not represent a form of “compassionate care,” as NGO reports asserted. Dr Mona even anticipated this kind of medical non-compliance from CCI patients and adjusted her care strategies accordingly. In conversations about her work, she imagined psychiatry as a “humane” intervention that disrupted, to some degree, the suffering associated with homelessness and abandonment. And yet, she quietly mentioned to me in the same conversation that psychiatry had its limits with homeless children who routinely assert their independence from adult authority figures. As a seasoned child psychiatrist and medical humanitarian, Dr Mona seemed to accept this irreconcilable tension inherent in her aid work.

Nada and Amir’s encounters with biomedical aid at CCI speak to a central paradox I aim to address in this article, one that is often overlooked in critical studies of humanitarianism and global health. What does it mean when children reject the international aid that has been framed as operating on their behalf? How do Nada and Amir’s reactions toward lice medication and psycho-pharmaceutical trouble conventional notions of what homeless children need, or how they consume global medical aid? In actively shaping the ways in which care is delivered on the ground and in voicing dissent, even fear, of medical intervention, Nada and Amir complicate the figure of the passive “street child” in international aid and urge us to reconsider the situated conditions and contradictions inherent in aid for homeless children today.

A paradox of care

The subject of how children respond to international aid that takes their bodies as objects of care and concern frames this article. Didier Fassin (2013) notes that children are absolutely central to humanitarianism. And yet, children’s experiences of international aid remain sparse in scholarship, especially in critical studies of global health and medical humanitarianism (Biehl and Petryna, 2013; Bornstein and Redfield, 2010; Redfield, 2013; Ticktin, 2011). This lacuna is surprising given the fact that, as Bianca Dahl (2014) notes in a recent ethnography on child orphans in Botswana, the political stakes surrounding the care of children’s bodies are central to humanitarianism. Dahl argues that global interventions targeting children’s bodies are increasingly a “hallmark” of large-scale aid initiatives today (p. 629). To this end, I build on a growing line of theoretical inquiry focused on aid and children’s bodies. By foregrounding children’s voices in my study, I extend debates on the prioritization of the “biological” and “suffering body” in international humanitarianism (Fassin, 2012; Petryna, 2002; Ticktin, 2011). Such debates have, to date, grown almost exclusively from ethnographic studies showcasing adult experiences of medical aid. Less attention has been paid to how children understand their humanitarian subjectivity as consumers of global health policy. Children—particularly vulnerable children in the global south—figure differently in medical aid regimes. Their bodies are conceptualized through metrics that emphasize human underdevelopment and biological immaturity. They are described in policy as passive and more physically vulnerable to poverty and violence than adults. Ironically, in a key medical manual used by CCI in training sessions, depictions of child biology elide discussions of gendered childhoods, despite the fact that gender shapes the ways in which aid is distributed and experienced by children on the ground (Sweis, 2012). In addition, street children, along with orphans and child refugees, are considered the most vulnerable of child groups and are therefore approached as most deserving of medical assistance. In Egypt, adfāl al shawāri’ are inextricably linked with discourses of national public health and crisis, especially the social and moral threat of childhood sexual transgression and disease (Nada and Suliman el, 2010). This heady focus on the biological dimensions of childhood suggests that, in the eyes of aid experts, children suffer differently and more intensely through their bodies and with a range of different social effects.

In order to explore how children understand and negotiate international medical aid, I conducted research in Cairo, Egypt, the Middle East and North Africa’s largest and most populous city. Cairo has remained a global hub for global development aid and child-rights advocacy since the 1990s, when Middle Eastern states adopted the language of universal children’s rights and a growing “street child problem” first emerged in Egyptian NGO policy (Fahmi, 2007). With an estimated population of 50,000 homeless children, Cairo thus served as an ideal site for an ethnographic investigation into how children consume medical aid over time (Bozack, 2012). I conducted over 2 years (2007-2009) of fieldwork with CCI, concentrating my time in its free medical clinic and homeless children’s shelter. The research took place mostly among a group of 30 children referred to by aid experts as homeless and abandoned adfāl al shawāri’ or in NGO terminology, “street children.” The majority of the narratives captured in this work derive from my long-term observations as an unpaid volunteer who was also granted formal research privileges. At CCI’s shelter, I conducted in-depth and life history interviews with adult aid workers and children who were informed about my research intents and who consented verbally. In addition, I spent time with children as they worked and socialized in neighborhoods, street corners, and alleyways. These sojourns were made in large part at the children’s request. Over time, they viewed me as a familiar adult friend who wielded limited power at the shelter but who served as a source of friendship and support on the streets. My goal throughout the research was to grasp the complexity of the children’s everyday lives, both within and beyond the organization’s borders, and capture their narratives, to the best of my ability, from their perspective (Cheney 2011). ⁴

Based on these observations and interviews, I argue that international medical aid represents a paradox of care for homeless children in Cairo, a simultaneously “productive and limiting force” (Biehl and Petryna, 2013: 27) in their lives. On the one hand, children were recognized as worthy, legitimate objects of aid and compassion through their globally recognized status as homeless or abandoned “street children.” On the other hand, their suffering was framed as an individualized biomedical problem requiring expert intervention and humanitarian governance (Fassin, 2012; Feldman and Ticktin, 2010; Pandolfi, 2003). Care, in turn, represented a strategy for managing homeless child bodies (not eliminating child homelessness) and disciplining individual children as particular kinds of healthy, rights-bearing subjects. The child in this view is approached in aid policy less as a social sufferer (Kleinman, 1988) embedded in larger historical, political, and economic systems of violence and inequality, and more as what I call a biological sufferer—a depoliticized figure imagined through the paradigms of Western biomedicine and universalized children’s rights (Cheney, 2007; Honwana and De Boeck, 2005; Malkki, 2015; Montgomery, 2001; Stephens, 1995).

Beyond biology: How children resist and negotiate medical intervention

As Nada and Amir revealed, the problem with aid that targets individual child bodies is that it erases children’s performative subjectivities and capacities to actively shape relations in everyday life. They also eclipse the complexity of the adult–child relationship during medical aid encounters and the ways in which that relationship resembles a “two-way street” (Hunleth, 2013) or can serve as a forum for children’s resistance to biomedicalization (LeFrancois, 2006). When homeless children are approached in aid policy through the logics of universal biology, they are assumed to suffer in the same ways, everywhere, according to the same effects. Such an approach obscures local conditions and constraints, as well as the situated practices young people engage in as they navigate poverty, discrimination, and state violence—from avoiding the police to meeting economic demands. Moreover, medical aid for homeless children contributes to the medicalization of poverty, a strategy that draws on so-called objective scientific measures focused on individual bodies to alleviate human suffering, rather than a focus on the large-scale social, economic, or political systems that produced poverty (Englund, 2006; Ferguson, 1994, 2006; Gupta, 2012; Roy, 2010).

Thus, I move away from the view that responds to homeless children’s suffering through biological metrics because children at CCI did not resemble the apolitical medical subjects authorities imagined them to be. They worked on the streets, negotiated the terms and conditions of aid in their lives, influenced how doctors delivered care, and neither rejected nor wholly embraced aid as they strategized to make the most of daily life. Aid workers routinely improvised care practices in relation to children’s agency, complicating how medical encounters were imagined by policy-makers. These messy, on-the-ground realities shed important light on the limits of medical aid for homeless children (Bornstein, 2005; Nguyen, 2010). As Biehl and Petryna argue for global health care more broadly, the global health community and healthcare advocates should take into account the “unpredictable social” that emerges from global aid encounters. Similarly, my research suggests that the producers of aid policy should make conceptual space for the unpredictability—or what Dahl (2015) refers to as the “micropolitical effects”—of aid encounters with children as well.

In calling international medical aid a paradox of care and in showcasing how children resisted interventions, I do not claim that children did not benefit from the resources or relationships that were available to them at the shelter. Nor do I believe they did not become healthier—in the biomedical sense—as a result of the care that targeted their bodies en mass and which aimed to optimize their vitality and quality of life as a homeless child “population” (Foucault, 1991, 1997; Rose, 2006). Indeed, during my fieldwork, I watched children receive necessary antibiotics for infections and have bleeding wounds dutifully cleansed and bandaged up in the aftermath of playground accidents. These are not the kinds of medical encounters I wish to address or question here. Rather, by observing how medical aid was mobilized to play a long-term regulatory role in children’s lives and by illustrating the limits of that regulation, I suggest there are more complicated ways in which scholars and policy experts can think about child-centered global healthcare arrangements.

Scholars have recently critiqued global humanitarian “regimes of care” that, in their quest to alleviate human suffering, increasingly approach populations through their biology. Miriam Ticktin (2011), for instance, illustrates how social and political differences on the ground are rendered invisible by a focus on universalized biology or “bare life” in humanitarian policy. This global trend dates back to 1971 with the rise of the international organization Médecins sans Frontières, where we witnessed a privileging of corporeal care in humanitarian practice, a “new humanitarianism,” focused almost entirely on health, doctors, and bodily integrity (Ticktin, 2011: 16). Since then, entire vulnerable populations have been represented in state and bureaucratic discourse through conceptualizations of their biological suffering, or their “biological citizenship” as Adriana Petryna (2002) notes in an ethnographic study of victims of Ukraine’s Chernobyl disaster. Stefan Ecks (2005), in an investigation of antidepressants in India, also recounts efforts to uplift the poor through the production of their “pharmaceutical citizenship,” a status that holds the promise of future demarginalization. These and other recent studies elucidate how contemporary medical interventions with the vulnerable are also framed in the equally universalizing discourse of human rights (James, 2010). Consequently, aid policies situated at the nexus of biology and rights wield the power to define who counts as worthy subjects of aid and who does not (Feldman and Ticktin, 2010). Along with its limited reach, these oppressive, exclusionary aspects of medical aid have garnered criticism from researchers concerned with local responses to medical intervention (Dewachi, 2015; Fassin and Pandolfi, 2010; Trapp, 2016).

I witnessed similar policies at CCI, where adfāl al shawāri’ were required to participate in healthcare practices driven by international children’s rights and biomedicine. It consisted of group showers, medical and dental checkups, haircuts, finger and toe nail clippings, ear cleanings, collective hand washings, and sports and fitness classes. The medical “humanitarian reasonings” (Fassin, 2012) justifying these practices asserted that health was a fundamental right of every child in Egypt. In 2008, CCI played a critical role in the implementation of universal children’s rights in Egypt’s child law. The “child” in the new law was constructed according to a Western, middle-class model of embodiment and domesticity (Bhabha, 2005; Shepler, 2005; Stephens, 1995; Sweis, 2012), which exhibited a “profound absence of historical, cultural, and biographical specificity (Malkki, 2015: 85).” Children were described in biological terms as physically vulnerable, autonomous, and underdeveloped. They were also constructed as passive subjects who are wholly dependent on adults and as apolitical figures with the right to play and enjoy an education (but not work). This rights-based approach to the child assumed a purity and innocence to “childhood” which clearly stands in opposition to the implied “messiness” of adulthood (Montgomery, 2001). In other areas of the law, the category adfāl al shawāri’ was constructed as a vulnerable population that suffers from “psychological trauma,” a revision that further framed homeless children as medicalized subjects with little attention paid to the socioeconomic conditions that produced child homelessness in the first place.

However, as Nada and Amir demonstrated above, children struggle during humanitarian encounters and sometimes engage in medical non-compliance. In doing so, they challenge the universal model of childhood through which medical aid regimes operate in Egypt. During my fieldwork, children frequently moved in and out of the shelter to work, visit friends in nearby neighborhoods, and gain independence from adult aid workers. They actively negotiated with adults and met long-standing kinship obligations despite their constitution in state and NGO discourse as “homeless” and “abandoned.” These nuanced practices of negotiation and decision-making demonstrate how fluid and conditional children’s positionalities are within and outside of humanitarian spaces. Moreover, they reinforce the ways in which young people are no less political, historical, or social than adults (Heidbrink, 2014). In moving away from an analysis of international medical aid’s good/bad effects, I instead wish to emphasize in this research how CCI operated through logics that recognized children’s biological integrity but not their performative agency as gendered subjects, nor the systemic poverty and structural violence shaping their everyday lives.

To help concertize these points, I share Nada and Amir’s life histories below. Together, their stories suggest that an emphasis on corporeal care in aid fails to address vulnerable children’s agency, as well as their painful experiences with structural poverty.

Telling children’s stories: Nada

According to CCI workers, Nada was 10 years old when she joined the shelter. She was 11 at the time of my research, but I initially thought she was 8 due to her unusually small body frame. Her clothes, donated to the shelter from foreign benefactors, always appeared too baggy on her body. Zipper-less jeans hung down loosely below narrow hips, making her seem shrunken and more delicate than she actually was. A worn out sweater or t-shirt typically lingered over a gaunt shoulder revealing a protruding collarbone and waiflike arms. But when she spoke, Nada’s commanding dark eyes, articulate speech, and adult-like gestures defied the child-like image her frail body projected. Like other children at the shelter, Nada did not attend school. Instead, she participated in informal classes at CCI where she enjoyed close friendships and a sense of solidarity with peers. In these classes, Nada cultivated a range of life skills such as writing Arabic, arts and crafts, and sketch drawing.

Nada began working near a tourist site when she was 8 years old. Although CCI strove to remove children from the streets by providing food, medicine, and housing, the children it serviced continued to work, seizing every opportunity to make money. Nada sold glossy black and white postcards depicting the Pyramids or Nile River to foreign tourists or middle-class locals who frequented the tourist site. On profitable days, Nada boasted to me and shelter workers that she “did good” selling postcards. She shared her income with her mother and two older sisters who lived under a bridge near the tourist site and whom she visited often. At one point in her life, Nada had a brother, but, as she explained, he passed away in a tragic accident. Nada told me her father had passed away as well and emphasized the ways in which that event had ruptured her life and was the source of her family’s impoverishment. In time, however, I learned from shelter workers that he had divorced her mother and taken on a new wife, leaving the family to live in desolation under the bridge. According to Amira, Nada’s young life is colored with emotional trauma resulting from her family’s tragic fragmentation and extreme economic vulnerability.

Nada’s subjectivity as a homeless girl was a resource on the streets, and it positioned her as an agent upon whom some adults depended. She would leave the shelter to work only when she thought it was most profitable, typically on weekend afternoons during tourist high season. I sometimes accompanied her when she worked, weaving my way through dense city streets as Nada held my hand and led the way. During one selling venture, we strolled past Abu Mohamad, a middle-aged male vendor who operated a tourist kiosk on a busy street. As we passed him, Nada proudly mentioned that she purchased her postcards from him at a negotiated rate of 1 Egyptian pound per card (less than US$0.25). She would then sell each postcard for about 5 pounds (just under US$1.00), yielding a substantive profit. Nada alternated her supply purchases between Abu Mohamad and Abu Ramy, another middle-aged male street vendor stationed on the same street. She emphasized how she had to purchase from both vendors in order to maintain positive relations with each one. As she explained, Abu Ramy noticed one day that she was purchasing postcards from his competitor and, having become quite upset, began pressing her for business. Viewed as an economic and social agent on the streets, Nada was left to strategically manage business relationships with multiple vendors. Together, Abu Mohamad, Abu Ramy, and Nada negotiated the same social landscape of informal labor dependent on precarious tourist income. However, Nada’s vulnerability as a homeless girl constituted a resource and situated her as an agent who simultaneously garnered compassion from adults and on whom adult vendors depended.

Street vendors were not the only adults who engaged Nada as a decision-maker with income-generating agency. She interacted with the police (zubat) who patrol all tourist zones in Cairo. In exchange for allowing her to sell postcards, Nada tipped officers approximately 2 Egyptian pounds before ending her shift. With this tip money, officers bought tea or cigarettes, which they consumed while on the job. Like street vendors, the police engaged Nada as an agent responsible for the capital she procured. Moreover, Nada’s practices with the police illustrate how children, and not only adults, craft powerful systems of morality and reciprocity through the gift exchange (Mauss, 2000 [1925]). When discussing the police with me, Nada stressed the unpredictable nature and precarity of her work. Sometimes, as she noted, new police officers would arrive at the scene and kick her out of her work zone, reflecting a climate of increased state securitization (Amar, 2013). Her countenance shifted from one of pride in the money she earned to one of pain as she spoke about these officers, who prevented her from working. Nada seemed to manage police encroachment as best she could. When she was prevented from selling, she returned to CCI where she knew friends awaited her and hunger, as well as boredom, could be remedied.

Neither fully drawing upon nor rejecting CCI as an institution of care, Nada’s practices problematize the passivity through which children are imagined in international medical aid policy. In shaping adult encounters on the streets and in the shelter, Nada demonstrates how children carefully navigate dual positionalities of performative gendered subject with social obligations—to family, vendors, and police—and vulnerable object of global health care (Hecht, 1998; Sinervo, 2013; Wolseth, 2014).

Telling children’s stories: Amir

At 14 years, Amir was the oldest boy living at CCI during my research. He practically grew up at the shelter. Often, I would hear workers refer to him by the endearing kinship term “Ibn CCI” (Son of CCI). On most days, Amir dressed in the same donated blue jeans, black Adidas flip flops, a red baseball cap, and white windbreaker. He spoke passionately to me about how he aspired to one day secure formal employment in a field such as qahraba (electricity) or combuter (computers) and therefore earn a respectable livelihood.

Amir was 10 years old when he moved into CCI after hearing rumors on the streets that it was a “good place” to be (makan kuwayyis). He was born in the low-income neighborhood of Faisal, located just outside the shelter. Amir’s life trajectory was one of tragic family breakdown and intensifying urban poverty. His mother passed away a few years before he left his crowded household. His father, an on-and-off truck driver, never remarried, and his older siblings—two brothers and a sister—struggled to meet the household’s demands and rising costs of living. Amir felt particularly disempowered in this household. As the youngest male, he often suffered physical abuse and intimidation from his father and older siblings. Yet, what eventually compelled him to leave was a domestic conflict related to economic demands at his public school, demands his father could not or refused to meet. This is how he described the life-transforming incident to me: he asked his father one day to take care of important administrative fees at school. “He just wouldn’t do it, he kept ignoring me,” explained Amir reflecting on the event. Amir viewed his exclusion from school as a major obstacle in life. In theory, public education is free to all Egyptians, but in practice attendance requires tips be paid to teachers and administrators. Increasingly, low-income families struggle to meet this rising, informal cost. Disempowered at home, excluded from school, and lacking an alternative system of social support, Amir believed the streets constituted a better, and more productive, place to be.

On the streets, Amir joined a network of boys ranging in age from 5 to 19. They traveled together in and out of busy city neighborhoods where they wiped car windows outside upscale restaurants or polished shoes around tourist zones for money. Although he was often subjected to social and police harassment, he found this work immensely profitable and attractive, earning him sometimes nearly 20 Egyptian pounds a day (at the time, this was approximately US$4.50). He saved half his day’s income and allocated the other half to that day’s expenses, which typically included cheap street food, cigarettes, hot tea, and sodas supplied by local street vendors. But Amir was not only working for his own survival and sense of independence on the streets. From time to time, he delivered a portion of his saved income to his younger sister, the only person he felt responsible for at home subsequent to his departure. Realizing the extent to which poverty governs her life, Amir’s obligation toward his sister stemmed from normative models of Arab masculinity (Ghannam, 2013), which included a fear that his sister would, as he stated, “do something shameful for money” and thereby tarnish his family’s reputation in their tight-knit neighborhood. Thus, while Amir constituted a vulnerable object of care at CCI, he also resembled a caregiving subject to a sister who did not qualify as “homeless” or “abandoned” and therefore remained excluded from CCI’s humanitarian realm. Here, the limits of international aid for the child appear twofold: first, for Amir, who challenges a universal model of childhood vulnerability and dependence, and, second, for his younger sister, whose poverty and suffering lay outside the purview of state and NGO policy.

I first learned Amir was consuming psycho-pharmaceuticals when I caught him swallowing a pill after lunch one day at the shelter early in my fieldwork. Hany, an adult male worker, handed Amir a white paper cup containing a tablet and then stood by, paternalistically, to supervise its consumption. He placed a gentle hand on Amir’s shoulder as the pill went down with a swig of bottled water. The medication was Tegretol, an antidepressant Dr Mona believed was mild enough for adolescents yet effective in stabilizing mood swings. During monthly psychiatric visits with Dr Mona, Amir spoke about his former household in Faisal, his time on the streets, and any difficulties he experienced at the shelter. During these sessions, Dr Mona monitored the effects Tegretol had on his behavior and reassured him medication was a necessary aspect of his emotional rehabilitation. CCI’s eventual goal was to guide young patients to emotional normalization or “mood stabilization” after experiencing “trauma” on the streets. It is important to note here that in CCI policy, the portrayal of childhood distress was framed in biological terms, legitimizing a bias toward biomedical—or pharmaceutical—solutions to childhood suffering (Mills, 2013).

Like other researchers who have documented children’s resistance to psychiatric medication (LeFrancois, 2007, 2013), I too discovered that Amir viewed his medication, along with psychiatric care in general, as a form of social control. He confessed that he does not appreciate the adult oppression and loss of freedom (huriyya) he experienced at CCI. Rules and hierarchies between adults and children suffocated him, as they did in his former household. For these reasons, he would periodically run away from the shelter for anywhere between a week to several months. During these departures, he returned to making money on the streets and reconnected with old friends. He would check up on his sister and regain a sense of masculine independence. While on the streets, he discontinued Tegretol consumption and, in an act that directly challenged CCI’s efforts of humanitarian governance, reengaged in smoking cigarettes. Each time he returned to the shelter it was only, as he puts it, to reunite with friends there and, like Nada, enjoy a necessary respite from street life. As mentioned earlier, Dr Mona anticipated Amir’s departures and returns and reluctantly accepted his medical non-compliance. This was precisely why, as she emphasized, Tegretol was her ideal drug of choice: it did not cause harmful side effects if treatment was abruptly terminated.

In Amir’s narrative, we observed how medical practitioners improvise care in relation to children’s agency. Amir’s history of leaving the shelter to reengage in informal labor was not uncommon among the children at CCI. As in other contexts around the world, children who work and live on streets creatively strategize and draw upon various local and international resources while participating in friendships and providing care for siblings and other kin (Montgomery, 2009). However, Amir’s case reveals how homeless boys negotiate their masculinity as child humanitarian subjects. His ongoing desire for independence through money-making, his returns to the shelter in order to benefit from some aspects of sociality there, his kinship obligations to his sister, and his mutual shaping of the psychiatric diagnosis process all paint a more nuanced picture of how children receive international aid and how medication represents a complex site of struggle for homeless children.

Conclusion

While research on global health has explored the limitations of aid with vulnerable adults, this article considered how children unsettle an international model of health care as they actively negotiate medical encounters with adults. Drawing on CCI’s work with adfāl al shawāri’ in Cairo, I have explored how Nada and Amir—two children whose stories were not unique—negotiated relationships in and outside of the shelter, strategized to make money, and split their time between the streets, their households, and the organization. When they returned to CCI, Nada and Amir quickly slipped back into the daily routine there, reconnecting with friends and participating in mandatory activities, until they decided to leave again. Workers at CCI recognized their limited authority with Nada and Amir even as they aimed to ambivalently govern them according to NGO policy, having come to terms with the “messiness” of children’s social and economic worlds beyond the shelter.

CCI policy was driven by universal discourses of biomedicine and children’s rights. It constructed “street children” as wholly passive undeveloped subjects and as biological sufferers requiring targeted medical responses. Yet, I have demonstrated how children remained connected to former households through enduring kinship ties, how they made critical decisions for themselves, and how they positioned themselves vis-à-vis adults as gendered political subjects—from street vendors, to doctors, to the police. Nada and Amir struggled to manage their poverty while drawing on and contesting aid. At times, they even “refused to be governed” (Scott, 2009) by biomedical regimes, as with the examples of Nada’s lice treatment and Amir’s non-compliance with Tegretol. Their resistance practices and mutual shaping of aid encounters destabilized CCI’s definition of childhood passivity and dependence. They also challenged a humanitarian privileging of biology over social and economic welfare. Like other children at the shelter, Nada and Amir viewed themselves as active subjects whose vulnerabilities were inseparable from those of others around them. In seeking out and rejecting aid, they remained only partially governed by the organization’s humanitarian apparatus: a key paradox I have aimed to problematize in this article.

CCI and other international NGOs continue to privilege children’s biological integrity in policies focused on “street children” worldwide. This follows a global trend within a “new humanitarianism” that recognizes the human (biological) body as the ultimate site of political intervention, one that supplants other pathways to social justice (Fassin, 2001; Ticktin, 2006). In these international policies, childhood suffering is defined through apolitical, scientific measures that call for targeted biomedical responses from NGOs—from pharmaceuticals to cure depression to mandatory lice medication as a means to “healthy” childhood. Without discounting the relevance of such interventions, we should nonetheless also ask what other forms of vulnerability (vulnerability tied to global capitalism or neoliberal state violence) and what other conceptualizations of the child (the child as a performative subject) are undermined or rendered illegitimate by a focus on biology. Nada and Amir’s subjectivities as recipients of care and as caregivers in a context shaped by urban poverty challenge the ultimate aims of international medical aid. They do so while illuminating a deep anthropological tension—an inescapable friction ⁵ —between universalized biology, on one hand, and diverse vulnerable childhoods, on the other. In these ways, aid policies that approach the child as a biological sufferer—rather than a political or social sufferer—can produce a set of contradictory consequences onto which scholars and child advocates should shift their attention.