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 the buildings as barracks and headquarters and the
llustration 1: from 2001 Demographic and Health Survey (MOHS, 2007)
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
Illustration 2: from the 2001 Demographic and Health Survey
clean drinking water and dignified sanitation facilities” (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 land- 57% to 73%, and child mortality decreased 5% each year
holdings demonstrating increase from 1995 to 2003
(Macours 2010, 5) (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 Illustration 7: Indices of growth and nutritional status for each group
including Height-for-Age, Weight-for-Age, and Weight-for-Height-for-Age
remain in contact with their families, often returning (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 glue-
sniffing to heroin, the majority of addicts are street children. Historically, marijuana has featured in cultural-
religious 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 Illustration 10: Mean height and standard error of mean of Nepalese
boys (a) and girls (b) with WHO 2007 reference data (Ghosh 2009, 42) 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 under-
developed 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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