Child deprivation and exploitation in Nepal: the effects of poverty and conflict from a development and health perspective

Nepal is classified as a “Least Developed Country”, with a rank of 142 of 177 on the UNI Human Development Index (Kohler 2009, 231) and over 50% of the population under 18 years of age (Singh 2006, 948). It is a truism that with poverty, comes suffering. Nepal has long been noted for the concerning prevalence of malnutrition and child labour. Equally patent is the fact that the political unrest of the last decade, in which violent conflict has claimed at least 13,000 lives (Insight 2010) can in no way have helped the situation. Constant blockades resulted in the increasing isolation of already remote regions. Schools and hospitals were frequent targets of attacks, regularly bombed. The insurgents used
I llustration 1: from 2001 Demographic and Health Survey (MOHS, 2007)

the buildings as barracks and headquarters and the government endeavoured to prevent this. At least 300

schools are still shut down as a result, depriving more than 100,000 children of education. Health workers and doctors found it difficult to practise: in addition to deporting many foreign doctors, the government imprisoned anyone practising medicine outside of a licensed location, declaring them terrorists. In addition to the thousands of people who fled the country (mainly to India), there are massive and still unknown numbers of internally displaced persons. In 2009 the government estimated 70,425 people had been displaced but that the majority had now returned home, and bases all assistance from this estimate. Independent figures are in stark contrast, with various NGOs estimating 50-70,000 still unable to return home and between 80-100,000 having settled in Kathmandu. Human Rights Watch estimates an additional uncounted 40,000 children. (Internal 2010) Nepal's population is roughly 25 million, with over 90% in rural regions. 31% of the population lives under the poverty line (some regions, as much as 60%) and over 40% live on less than $1 per day. One of the poorest countries in Asia with a GDP of only $386, Nepal is also the most stratified with a highly uneven income distribution and “significant inequalities in... health, education, and access to clean drinking water and dignified sanitation facilities”
Illustration 2: from the 2001 Demographic and Health Survey (MOHS 2007, 3)

(Kohler 2009. 231). Although the rural – urban divide is the greatest, “social exclusion takes place at the level of interactions among individuals within the household/family and in economic activity and livelihoods... in the community, in local institutions, and at the national level” (Kohler 2009, 231). The country's position between India and China has lead
Illustration 3: (Green 2009, 71)

to a high degree of ethnic diversity. Culturally, much is

organized around a caste-system that although characterized by Indian immigrants as less “intense” and “discriminatory” than that practised in many regions of India is nonetheless a major factor in daily life. (Weiner 1971; Subedi 1991) The government has officially recognized women, Dalits (the lowest caste), Janjatis (ethnic foreigners), Muslims, people from remote regions, the disabled, street children and orphans, and children from displaced and conflict-affected families (Subba 2008, in Kohler 2009). Dispite significant Tibetan and Burmese refugees entering Nepal, the majority of migration is across the Indian border which has historically been open; many families are diffused and their citizenship ambiguous. For the most part, unskilled labourers leave Nepal for basic work in India whilst better-educated Indians have increasingly dominated the emerging technical sector of Nepal. (Subedi 1991; Macours 2010) Culturally Nepal is syncretic yet extremely traditional: highly patriarchal with a great value placed upon agriculture and land-ownership. At one point, land ownership was a pre-requisite for citizenship – and many still believe this is the case. More than 80% of the population relies directly upon agriculture for their livelihood. Land is rarely sold, the majority of transfers through inheritance. There has been an increasing “feminization” of farming, particularly as men have entered the international labour-force, but women quite rarely own or inherit land on their own right. Since the 60s, there has been a great deal of INGO involvement in development and children's health issues with significant amounts of foreign aid from India, China, the US and the UK (Weiner 1971, 618). Of the 12.5 million children in Nepal, 3.5 million are under 5 years. 69% of children suffer from more than 1 form of severe deprivation from basic needs. 50% of the children are “stunted” and 13% wasted. 66% of children have parasitic infections (with half of those infected with more than one type of parasite). Infant mortality is at 6.4% and maternal mortality at 5.4%. Yearly, 70,000 children die from preventable diseases. There are an estimated 1.7 child labourers. (Singh 2006)

Illustration 5: (Green 2009, 74)

Illustration 4: (Green 2009, 74)

Political conflict & the growing gap The “civil war” that raged in Nepal from 1996 to 2006 began as a series of isolated uprisings and demonstrations by the Maoist movement. Although a multi-party constitution was signed in 1959, it was never fully realized, with the monarchy and government frequently overruling the parliamentary parties. Public demonstrations calling for reform and greater political involvement of the people were common through the 70s and 80s. The first democratic elections took place in 1991, but the situation quickly deteriorated. The Maoist party began attacking rural police posts; the government's severe and violent response escalated to the conflict to the point that, from 2001 to 2005, violence had broken out across the country, blockades and mass abductions and conscriptions of people, particularly school children were common. When the Maoists controlled most of the country in 2006, a peace accord was signed reinstating parliament and dismissing the King. It was not until 2008, after the government once more broke down (the Maoists quit the government and regions, including the Terai valley, began demanding independence) and spurts of violence continued, that Nepal was declared a republic. (Insight 2010) Macours (2006; 2010) and other analysts have concluded that the conflict was primarily sparked by relative, rather than absolute, deprivation and poverty. Many of the basic economic and demographic indicators have shown notable improvement over the last 30 years, yet the presence and escalation of civil conflict – traditionally explained as function of poverty and economic underdevelopment – during the same period seem counter-intuitive until a closer analysis shows that the improvements affected only the elite, leaving the vast majority of the population untouched, or even relatively worse off. The majority of development was internationally funded, coordinated, and organized; the government, when involved, were both unable and unwilling to regulate or evenly distribute the gains which were often seized by the higher-caste households or available only to urbanites. “Consumption gains between 1995 and 2003 occurred more than proportionately for households with relatively large landholdings, resulting in relative deprivation of the (near) landless.” (Macours 2010) The increase in consumption inequality creates “discontent by traditionally marginalized households who notice that other households in the same district are benefiting more from economic growth, while they are lagging further behind” (2006, 4) providing “salient support” for the Maoist insurgency by both increasing expecting benefits and decreasing the “moral thresholds” for the populace to turn to “criminal activity” (Macours 2010, 3) Between 1995 and 2003, the poverty prevalence decreased from 42% to 31%, primary school enrolment increased from
Illustration 6: Expenditures, total and food, by size of landholdings demonstrating increase from 1995 to 2003 (Macours 2010, 5)

57% to 73%, and child mortality decreased 5% each year (Macours 2010, 1). Little change in distribution of land

occurred during this period, but the wealth and concomitant quality of life of large landholders increased drastically [see illustration 4]. Additionally, many of the large rural landholders moved their primary residence to urban areas. Maoist discourse, including booklets issued such as the 1998 “Political-Economic Rationale of People's War in Nepal” focused on the injustice of this, calling for “land to the tillers” reform and highlighting the association of landlessness and poverty. (Macours 2010, 4) Furthermore, Maoist-related incidents affecting civilians (including murders, abductions, blockades, explosions, threats, expropriations/extortions, and personal attacks) were targeted in regions with the greatest stratification in land-holdings. Abductions, nearly 21% of all incidences, were used as the main recruitment strategy and mass abductions of school children and teachers formed 65% of all abductions, as collected from newspaper reports (Macours 2010, 9). “Abductees were brought to 're-education' camps and typically set free after a few days. Interviews... indicate that the rebels treated them nicely.” Definitive numbers are unknown, but at least 7787 people were abducted in May 2004 alone, and as many as 1500 people could be abducted in a single session (Macours 2010, 10). The targeting of stratified regions and marginalized peoples was an important strategy; that school children, often quite young, fit this criteria, demonstrates the effects that they bore of the increasing inequity and their disenfranchisement. Child exploitation Children were used not only in direct combat, but in a variety of capacities including sentries, porters, cooks, and messengers (Kohrt 2008). Interviews with villagers after an attack in 2004 suggested the vast majority of the Maoist combatants were 15-25 years old and members of disadvantaged ethnic and caste groups (Macours 2010, 23). It is known that both the Maoists and the Nepali Royal Army regularly conscripted children; numbers are unknown. Many children affiliated with the Maoists were placed in camps with the peace accord in 2006 and not released until 2008. (Insight 2010) That the detriment, physiological and psychological, that these children suffer is immense is a more than reasonable speculation: studies have shown levels of PTSD, depression, and anxiety are extremely high, as would be expected. Yet, this is also the case for the majority of children in Nepal who lived through and witnessed the conflict. Kohrt et al (2008) conducted a study comparing the mental health of former child soldiers to children who had never been conscripted. They interviewed former child soldiers identified by and currently in the care of NGOs (one child was affiliated with the Royal Army but was discounted from analysis for lack of a statistical sample; others had refused to participate). More than 50% were conscripted under 14 years of age and more than 50% had been directly involved in combat. Compared to the non-conscripted children,more demonstrated mental health scores above the cut-off points for PTSD and depression – but not anxiety. Kohrt subscribes this to the nature of trauma experienced and the role to which they perceived their degree of involvement and control. A surprising number identified themselves as “still affiliated” and awaiting orders to return to combat and, relative to those who did not, showed better mental health scores. Whether these better mental health scores were causal – those more capable still willing to be affiliated – or a result of delayed psycho-emotional response is unclear. Girls had significantly worse mental health scores; this is speculatively contributed to sexual abuse (deemed culturally inappropriate and not discussed in interviews) which, conjecturally, would have been much worse for those affiliated with the Royal Army, given the Maoists focus on female rights

and gender equality. Additionally, girls were less likely to be accepted by their families after having “left home” and served with a military force. Son-preference and male privilege has long shaped child labour in Nepal. Women have drastically lower inclusion scores in all cultural and economic aspects, lower rates of literacy and education, across all social groups. The male-female literary differential was 20% in 2001 and most indicators have seen little change in rural areas since the 80s (Koolwal 2007, 884). The disadvantaged caste and ethnic groups, however, demonstrate an even more dramatic gender-gap. 79.4 % of Dalit women married before 18, as opposed to 52% of high caste women. (Allendorf 2007, 1977) Boys are much more likely to be sent to school while girls are kept home to help the household. Employment outside of the home is common. The legal minimum age of employment, 15 years, is openly flaunted. In 1996, 41.7% of children 5-15 were working regularly and 55% of working children were girls. That girls, who are culturally expected and encouraged to be kept within the home, formed over half of those working outside of the household is noteworthy. The number of working girls exceeded boys in all regions. 74% of working boys also attended school, compared to only 51% of girls. (Koolwal 2007, 882) Much like the use of child soldiers, the number of children trafficked and the results of that exploitation are difficult to quantify. The international definition of child trafficking involves the illegal movement of children across borders for not only sexual exploitation but domestic work and forced labour in factories and circuses. The patterns of trafficking are shaped by inequities in resources and women's' status. Nepal is a “source country”, along with Bangladesh, Myanmar/Burma, and Vietnam, with “destination countries” traditionally India and Thailand but increasingly including Saudi Arabia, the UAE, and Hong Kong. It is estimated that 12,000 women and children are trafficked from Nepal each year, with 5-7,000 Nepali girls taken to Indian brothels. For the most part, girls are lured by offers of marriage or domestic work, with the majority “sold” by a family member. (Crawford 2008, 906) Sex workers, involuntary or otherwise, have extremely high prevalence of STDs, including HIV/AIDs. India has the world's largest HIV epidemic and Nepal, which has yet to see a significant rate of infection, lacks educational programs and knowledge of the disease. Many turn to drugs and studies of female drug users in Indian brothels with a history of prostitution have extremely high prevalence of suicidal attempts and depression. Presumably, the mental health affects would be even more intense for girls trafficked (Tsutsumi 2008, 1842). Those that manage to return are rarely accepted back by their families and communities, due to the associated shame of “sex work”. Mere suspicion brings great shame to community, ineligible for marriage. The prejudice is so strong that there is debate as to whether reintegration is even advisable or worthwhile for survivors. A senior official at an international aid organization in Kathmandu described trafficked girls as “dead meat”. (Crawford 2008, 909) Programs which focus on vocational skills alongside psycho-social support have been the most successful. Tstutsumi (2008) and Crawford (2008) interviewed women in care programs who had survived attempted and completed trafficking to sex-work in India. Tstutsumi compared the profiles of those trafficked to be sex workers to the profiles of those trafficked for other intentions – noting that many were passed between different traffickers and “jobs” along the way – and found that the sex workers, in general, had had fewer living family members, less education, were less literate, and less of them had been sold by an immediate family member (13.9% as compared to 30%) and had been trafficked at an older age (mean of 16.7 as opposed to 11.73) and the full 100% of former sex workers were above the cut-off levels for depression (as opposed to 80.8%).

Crawford looked at a reintegration program and found that the best predictor of improvements in long-term mental health were social acceptance. Reintegration into society at large seemed to be determined by the acquisition of vocational skills (candle-making, sewing, food-processing) while reintegration into their “homes” more difficult to assess – a slow approach of gradual reintroduction seemed the most successful but families who expressed no desire to hear news of their daughters or reacted negatively where not approached further. Although analysis was stymied by the number of women who refused to participate in the study and the even greater number who dropped out and disappeared, the “success stories” of the NGO seemed legitimate – if not necessarily evenly distributed – and hopeful. Overall, the need for anti-trafficking outreach programs in rural areas to make families aware of the risks, negate the seeming benefits, and to diminish the associated stigma to enable girls to recover and thrive post-trafficking is apparent. Boys who leave home early, whether trafficked or voluntarily independent, fare much better. A conservative estimate places 5,000 homeless children on the streets of Kathmandu (Rai 2002, 18). Studies of street children differentiate between families of “urban squatters” and homeless children. Boys on the streets are much more visible than girls, to the extent that studies of street children have been largely unable to include girls as they are simply unavailable. Girls selected for studies often refused and there is indication that many girls disguise themselves as boys when living on the streets. (Rai 2002, 17) In 2001, 8.9% of girls under 18 lived without either biological parent as compared to only 5.8% of boys – although a slightly larger number of boys identify as orphaned, at 5.4% as opposed to 4.9% of girls (MOHS 2006, 28) Boys are more likely to engage in wage-activities and much more likely to remain in contact with their families, often returning
Illustration 7: Indices of growth and nutritional status for each group including Height-for-Age, Weight-for-Age, and Weight-for-Height-for-Age (Worthman 2008, 246)

seasonally to the villages and farms. Comparative biophysical markers consistently show that homeless boys are healthier than rural village boys – although urban squatters are worse than either group, demonstrating it is not a purely environmental urban/rural difference – with lower rates of infection and better nutrition. Mental health, however is a notable exception with homeless boys they demonstrate higher rates of anxiety and depression (Worthman 2008). Whether the relative biophysical health of homeless boys is explained by their lifestyle or whether their health explains their lifestyle is worthwhile speculation: that street boys are a self-selecting group consisting of the ablest of the poor and are able to improve, or at least perceive a short-term improvement in, their circumstances by voluntary homelessness, a far from ideal condition, highlights the severity of rural conditions. Implicit in “street life” is another set of adversities – notably, drug use. Between 25-90% of street children regularly use substances (Rai 2002, 21) and perhaps 10% of Nepali teenagers are addicts (Rai 2002, 20). Substance abuse, particularly narcotics, has long been seen as an externally-induced foreign problem in Nepal. Neither a source of drug crops nor part of the trafficking route, the problem is nonetheless growing: from gluesniffing to heroin, the majority of addicts are street children. Historically, marijuana has featured in culturalreligious rituals. For a period in the 60s and 70s, Nepal became a “Shangri-La mountain paradise” for “drug-using hippies” who introduced heroin. Legislation quickly cracked down and there have been very few documented

cases of foreign drug use since, but popular – particularly government opinion – still characterizes drug use as tourist-driven. Jutkowitz (1997) undertook a small-scale study of heroin users in Kathmandu, none of whom were drawn into use by foreigners. Many had initiated use following other drugs and homelessness, and when unable to afford heroin they turned to various chemical alternatives to smoke and inject. Both anecdotal and studies indicate that the most common form of intoxication is, by far, glue-sniffing and that it is so embedded into “street culture” as to serve as a form of induction to new homeless children. Reasons stated include relief of tension and as a meal replacement. (Rai 2002, 43) Children's Health – The Big Picture Malnutrition is by far the most ubiquitous of children's health issues in Nepal. The WHO estimates that half of child deaths under 5 years are associated with malnutrition. According to the 2001 Nepal Demographic Health Survey, more than 50% of Nepali children are “stunted”, with a height for age less than 2 standard deviations below norm. (Pramod-Singh 2009, 144) Despite
Illustration 8: (Green 2009, 75)

the “healthy but small” debate, the grave consequences of undernutrition and stunted development are well established biomedically; those who do not starve are predisposed to infections and other illnesses with both physical and psychological ramifications. (Pramod-Singh 2009, 145) “The failure of children to reach their developmental potential and achieve satisfactory educational levels plays an important part in the intergenerational transmission of poverty.” (Grantham-McGregor 2007, 61) Studies of Nepali children indicate that

Illustration 9: Mean weight and standard error of mean of Nepalese boys (a) and girls (b) with WHO 2007 reference data (Ghosh 2009, 42)

Illustration 10: Mean height and standard error of mean of Nepalese boys (a) and girls (b) with WHO 2007 reference data (Ghosh 2009, 41)

nutritional programs have a massive impact (Ghosh 2009; Morrison 2008; Pramod-Singh 2009). While health programs can do much to alleviate the socio-economic differences in health outcomes, access is crucial. Growth stunting is the most visible indication of poverty, adversity, inequity, and vulnerability. Historical caste-discrimination is re-evidenced, even perpetrated in contemporary socio-economic growth. Although Nepal has seen great improvement in health indicators and the conflict is seemingly resolved, there is new and alarming potential in the damage already wrought. The child soldiers and displaced children, particularly the girls, have an incredible burden of PTSD and mental health to bear. Those who cannot return home will join the urban street children, likely turning even more to drugs and prostitution. Those who are needed as a labour resource for their families will seek what employment is available – and, likely, outside of Nepal. Labour patterns have enforced migration and will likely continue to do so, further destabilizing a nation in a critical period of growth. As in all regions with endemic poverty and violent conflict, children are the most vulnerable and, in Nepal, this is evident with the abduction of children for recruitment as soldiers, the massive displacement and orphaning of children, the destruction of schools and hospitals and disruption to the educational system and medical programs. To blame the issues of children's welfare (mortality, morbidity, and exploitation) on poverty is as much a gross oversimplification as to blame the conflict on poverty. A more subtle truth invokes the mechanisms through which the caste system, urbanisation, and rural privation resulted in migration, inadequate medical care and education, outright violent conflict and child exploitation; all of which, in turn resulted in the growth stunting, mortality, morbidity, mental health and substance-abuse problems exhibited by the children of Nepal. The development and welfare programs of Nepal, while well-intentioned and humanitarian, are not only mainly foreign-funded, but non-sustainable – many were unable to withstand the conflict – and most ameliorate the present, rather than preparing a future. The demography and economics make the exploitation of children a sad inevitability, as they represent the largest resource available. That these children will grow up seems self-evident, but the question of what will occur when that does happen, whether these children will in turn exploit the next generation, demands attention.

Personal Note
My interest in this topic stems from my association with a Kathmandu-based international non-governmental organization (INGO) focused on improving children's welfare in the changing post-conflict setting. The Umbrella Foundation began as a response to observed neglect, abuse, and corruption seemingly wide-spread in local “orphanages” and has since become involved various programs ranging from education, medical, and what they term “village rejuvenation”. In addition to spending three months in Nepal, where I primarily worked on updating the website and promotional materials in addition to visiting village sites, I continued fund-raising for the Umbrella Foundation from Los Angeles. My first year in Bristol, I worked as a charity fund-raiser for an agency that represented various large INGOs. These experiences aroused my interest in issues of human rights and development, the sustainability of local “green-grass” initiatives as opposed to large “charities”, the institutionalization of development programs, the interventionist paradigm and the manner in which the issues of underdeveloped nations are presented, or rather, marketed to citizens of “first world” nations. These experiences, including visits I took to the villages of Dola Re and Dhadhing Besi in Nepal were I stayed as a guest, experiencing from the incredible hospitality of impoverished families and the surprise with which I found myself in conversations with young Nepalis of my own generation whose knowledge and passion were impressive, framed my understanding of the great and inherent complexity, contradictions and complications, involved. While I strongly avow sustainability as the primary concern for development, it is not my intention to evaluate the development industry of Nepal other than to note and contextualize the bias of my interest.

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