Besides those mentioned above, there are also other semi-migratory groups not usually considered in the migration figures, whose practices are also cited as contributing to the spread of HIV and AIDS in Nepal. Seddon includes the following groups:
Truck drivers taking loads to and from India; smugglers operating across the borders; officials making formal visits; merchants and traders traveling on business; small farmers involved in seasonal or temporary labor migration—all of these are internationally mobile—and have become increasingly so—and may contribute to the spread of HIV infection into Nepal. (Seddon 1995:5)
Seddon, focusing on structure, views most of these occupational choices as strategies necessitated by the economic pressures of poverty.
Many other authors also cite poverty as the main factor contributing to migration in Nepal. Smith (1996:139) comments that among the populations of the middle hills, there is an ever increasing need for farming families (90% of Nepal’s population) to supplement their income through migratory labor. Sattaur (1993:15) reports that 6 percent of Nepal’s population owns 46 percent of the cultivatable land and that 75 percent of the population own less than one hectare (2.74 acres) of land. Sattaur (1993:15) also reports that the average family of five requires one hectare of hill land for subsistence. The average size of a Nepalese family sharing one hectare of land is well beyond five members. Beside this, heavy deforestation is creating loss of precious topsoil and is further reducing agricultural productivity. The result is that most families raise only enough food to support their needs for part of the year and then must rely upon supplemental income from family members who migrate to the city or abroad in search of work. The United Nations Children’s Fund cites increased population pressure, scarcity of arable land, limited food production, underemployment, debt, exploitation, and hunger as the main “push” factors for migration in Nepal (UNICEF 1992:14).
Nepal’s insufficient infrastructures (poor roads and communication systems) are also believed to structurally contribute to the spread of HIV and AIDS. Poor infrastructure begets poor education and illiteracy, which in turn, facilitates low awareness, which then cultivates the spread of HIV and AIDS. Likewise, as mentioned earlier, these same issues create structural barriers to HIV treatment; availability does not necessarily mean access. The wider world’s cultural model of ART (solving the HIV crisis through treatment rather than prevention) is just not a reality for Nepal at this time. Even if available free, many barriers to HIV treatment remain: physical barriers—frequent strikes make travel impossible and bad weather often closes roads for days at a time; financial barriers—patients have to pay to travel to distribution centers and require food and lodging while there (they are taken away from work for the time required and cannot leave unattended children at home, etc.); and the stigma associated with HIV. Many of these barriers will be evident as I discuss newly emerging HIV narratives in chapter six.
Conflict or war should also certainly be considered as a structural issue. The impact of war upon healthcare is well documented in the literature. Various authors have noted the direct and lingering effects of war on healthcare and healthcare delivery. Paul Farmer (2006) has commented that political instability and violence has had similar effects in Haiti. According to Farmer, “the deaths from Haiti’s cycles of violence do not all come by gunfire. Riots and revolutions, and lawlessness have also interrupted the healthcare that Haitians receive.” According to Farmer there are the obvious, directly related results of conflict that impact healthcare delivery, such as treatment of gunshot wounds, low blood supply, destroyed medical facilities, etc., but there are other more pernicious ways that disruptions in political systems can disrupt entire healthcare systems. He points out that treatment of chronic illnesses (such as HIV and AIDS) require a stable health provision system and this is severely impacted by conflict. War often means no functioning laboratories (due to destruction of facilities, disruption in power supply, etc) and lack of services and lack of equipment to treat people. And many health care providers, facing this lack of facilities and shortages of essential supplies, often depart in frustration. Likewise, many health care providers, fearing for their lives or the lives of their families (and because they have the financial resources to do so) will often depart these war zones for safer ground. The lack of necessary supplies and essential healthcare workers means the cessation of essential services vital in the ongoing treatment of chronic illness. Farmer has concluded that “you can’t do public health in a war zone. You can do your best to patch people up but you can’t really do good public health in the middle of political violence. It’s just not possible.” In relation to Nepal, several authors have noted the toll that the ten year long civil war has had upon the spread of HIV and AIDS in Nepal (e.g., Singh et al. 2005, Beine 2006, Karkee and Shrestha 2006, Pokhrel et al. 2008, and Ghimire 2010). In one of the most poignant examples, Ghimire (2010) illustrates how “social separation” precipitated by war led both men and women of rural Rolpa District into behaviors that exposed them to the risks of contracting HIV.
David Seddon has also suggested that environmental degradation, a byproduct of poverty, has played a role in the spread of HIV and AIDS in Nepal:
The resources of the hill areas in the hinterland of the Kathmandu Valley urban centers, perhaps more than anywhere else in the country, have been progressively degraded and depleted as demand for wood fuel has increased over the past decades. With increasing land degradation and inadequate access to forest resources or land for agricultural production, the inhabitants of these areas have become increasingly reliant on selling their labor and their bodies to provide their families with a living income. (Seddon 1995:7)
Between 1950 and 1980, Nepal’s forest cover was cut in half and deforestation continues to occur at an alarming rate. Savada (1991:125) suggests increased demands for grazing lands, farmland and fodder for animals, combined with the growth of human population and people’s dependence upon firewood for energy, as the major factors inciting deforestation in Nepal. In turn, major deforestation has caused erosion that limits the future productivity of agricultural lands. Savada (1991:72) also suggests that the large migration figures from the mid-hills are “an unmistakable indicator of the region’s deteriorating economic and environmental conditions.”
We have seen that many authors have made a strong link between poverty and commercial sex work, migration, war and even environmental degradation, and that this factor (poverty) is facilitating the spread of HIV and AIDS in Nepal. These authors contend that the search for alternative forms of employment is most often a response to dire economic situations. Again, Seddon concludes:
The clear implication is that it is the degradation of resources and poverty that creates vulnerability and drives the rural poor, particularly from certain identifiable regions, into economic survival strategies that take them away from their homes to work elsewhere; migration is a necessity, and as far as employment is concerned, “beggars cannot be choosers.” (Seddon 1995:7)
It is not difficult to understand why such focus has been placed on Nepal’s poverty as the root cause of HIV and AIDS. Nepal is one of the world’s poorest nations as noted earlier. We have also seen, however, that there is a growing awareness that personal agency (including various cultural practices)