The Last Fron­tier

Text Pho­tos

Asian Geographic - - Environment - Zigor Aldama Zigor Aldama and Miguel Candela Ram Lalita

Lalita didn’t know that she had been in­fected with HIV un­til AIDS killed her hus­band. “He got very sick sud­denly, so we took him to a shaman. He per­formed a rit­ual and rec­om­mended tak­ing herbs, but it didn’t work. Fi­nally, we had to take him to the hos­pi­tal,” Lalita, who is in her for­ties, re­calls.

Lalita and her hus­band had to spend a rel­a­tive for­tune to seek help, and trav­elled 50 kilo­me­tres along the bumpy roads of east­ern Nepal to get to the near­est health fa­cil­ity – but all in vain.

At the Ma­hot­tari Hos­pi­tal, a shock­ing truth was revealed: Lalita’s hus­band, a mi­grant worker who used to have a job as an elec­tri­cian in In­dia, had had in­ter­course with Hiv-pos­i­tive pros­ti­tutes in the north­east­ern As­sam state. “He sent money from there and used to come back home about three times a year,” she says, try­ing to hold back her tears.

The an­tiretro­vi­ral pills she takes now keep her alive and are pro­vided

Ram “I tried to con­ceal the true rea­son of his death, but soon all the vil­lage knew”

free of charge by the Nepalese govern­ment. How­ever, fight­ing the dis­ease is not her sole hard­ship; fight­ing stigma and poverty are ad­di­tional bur­dens.

“After the death of my hus­band, I lost my in­come. So we sold the land we owned to feed our­selves and we went back to my par­ent’s home. I tried to con­ceal the true rea­son of his death, but soon all in the vil­lage knew.”

As a re­sult, her fam­ily ex­pelled them from their home, and par­ents in the town for­bade their kids from play­ing with Lalita’s two sons – even though they were con­firmed Hiv-neg­a­tive. She now lives in a rudi­men­tary hut and has to wash her clothes and uten­sils far from the stretch of river where oth­ers do the same. She has been com­pletely alien­ated and sur­vives on char­ity.

Un­for­tu­nately, she is not the only one. Nepalese mi­grant workers, es­pe­cially those trav­el­ling to other South Asian coun­tries for work, are at the high­est risk of be­com­ing in­fected with HIV on the con­ti­nent. The gen­eral lack of checks and health­care ac­cess in the most re­mote ar­eas makes it dif­fi­cult to as­sess care and treat­ment.

The Com­mu­nity De­vel­op­ment

Project (CDP), a lo­cal NGO spon­sored by Ac­tion Aid, sur­veyed 600 mi­grant workers in six dis­tricts and found that five per­cent had con­tracted the virus. None of the peo­ple sur­veyed sus­pected that they were in­fected.

“That’s a lot given the fact that many refuse to take the tests – es­pe­cially for those who paid for pros­ti­tutes,” says Biyay Ku­mar Chaud­hary, the cur­rent pres­i­dent of the CDP. “So we have started a cam­paign to re­quest that women re­frain from hav­ing sex with their hus­bands upon their ar­rival un­til they have been checked.”

Un­for­tu­nately, in Nepal, women don’t have a say. “That will make many Hiv-pos­i­tives re­main in the shad­ows un­til it’s too late,” Chaud­hary ex­plains.

Ac­cord­ing to sta­tis­tics from UNAIDS, mi­grant workers com­prise around 10 per­cent of the global HIV­pos­i­tive pop­u­la­tion – al­most the same per­cent­age as ho­mo­sex­u­als, and far higher than the four per­cent of drug users. “They are also bring­ing the virus to the low-risk pop­u­la­tion, be­cause

to flee and find shel­ter at the CDP. She got lucky: Thanks to the NGO, she aban­doned sex work and is now an ad­vo­cate for safe sex among pros­ti­tutes. “We have to do some­thing, be­cause if we don’t, the epi­demic will strike back,” she says.

The prob­lem, Binte ex­plains, is that “every­body in Nepal can be­come a mi­grant worker at some point, which makes it ex­tremely dif­fi­cult to screen the pop­u­la­tion.”

Nepal shares a 1,850 kilo­me­tre-long bor­der with In­dia, and cit­i­zens of both coun­tries don’t need a visa to visit, or work in, the neigh­bour­ing coun­try, so mi­grant work is com­mon.

“This mi­gra­tion pat­tern is very dif­fer­ent from that of the West. Most trips are tem­po­rary and linked to spe­cific cir­cum­stances, like a drought,” says Binte.

Ram Ba­hadur Go­tami is a good ex­am­ple. He left his small vil­lage near Pokhara be­cause of a dis­as­trous har­vest, and re­turned in very bad shape just a few months later. He’d lost a lot of weight, and suf­fered con­stant headaches. He was ad­mit­ted to the Western Re­gional Hos­pi­tal. His doc­tor, Basand Tam­prakar, de­cided to run a se­ries of tests. They brought him bad news.

“He is suf­fer­ing from clin­i­cal stage three of AIDS, so it will be very dif­fi­cult to save his life,” Dr Tam­prakar ex­plained at the time of the in­ter­view.

But Ram had no idea what that meant. He had never heard of AIDS, and be­lieved ev­ery­thing would be cured with pills. With in­creas­ing anx­i­ety, he waited for a nurse to ex­plain the sit­u­a­tion and to of­fer psy­cho­log­i­cal com­fort. “The lack of knowl­edge is deadly,” Dr Tam­prakar says. “From 1,162 ad­mit­ted HIV­pos­i­tive pa­tients, over 500 have got an­tiretro­vi­ral med­i­ca­tion. But 170 have

“We have to do some­thing, be­cause if we don’t, the epi­demic will strike back”

died. They seek help too late.”

An ad­di­tional prob­lem is that pa­tients re­quire a high-pro­tein diet, which is hard to come by in Nepal. Pre­vi­ously, NGOS sup­ported pro­grammes by pro­vid­ing as­sis­tance in the form of di­etary sup­port, but with the in­ter­na­tional eco­nomic cri­sis, dona­tions have slumped. In the West, AIDS is widely con­sid­ered a chronic dis­ease, so it re­ceives much less at­ten­tion; peo­ple would rather do­nate their money to other pro­grammes.

And that’s how the vi­cious cir­cle of AIDS keeps turn­ing in Nepal. Un­aware of the risks, count­less mi­grant workers en­gage in un­pro­tected sex with pros­ti­tutes work­ing abroad in South Asia or the Mid­dle East. Un­aware of their in­fec­tion, they re­turn to their spouses, and pass on the in­fec­tion, which can also then spread to their new­born ba­bies. A lack of proper health­care com­bined with so­cial stigma makes it much worse.

In to­tal, more than 5,000 peo­ple have died of AIDS in Nepal since the first case was di­ag­nosed in 1998. Still, 70 per­cent of the pop­u­la­tion doesn’t yet know any­thing about it.

In 2015 the coun­try launched its “End­ing AIDS by 2030” pro­gramme, and UNAIDS ap­plauded the ini­tia­tive. How­ever, the sta­tis­tics pro­vided in the 2015 re­port are not very en­cour­ag­ing. Only 26.5 per­cent of male re­spon­dents in a UN and govern­ment sur­vey ad­mit­ted to us­ing a con­dom dur­ing “higher-risk sex”, and only four per­cent of the pop­u­la­tion has been tested for HIV. The mother-to-child trans­mis­sion rate re­mains high at 35.7 per­cent.

For­tu­nately, cam­paigns have led to a 90-per­cent in­crease in safe sex prac­tices among sex workers, and 58 per­cent have tested for HIV. Over­all, UNAIDS be­lieves Nepal is moving in the right di­rec­tion. “The new in­fec­tion es­ti­mates also sug­gest that the trend of an­nual new in­fec­tion is de­clin­ing and will con­tinue to drop fur­ther if the same level of in­ter­ven­tion is main­tained. The an­nual new in­fec­tion cases is ex­pected to de­cline to 899 by 2020,” the lat­est an­nual re­port reads.

But UNAIDS warns: “Even a small preva­lence of HIV in the large pop­u­la­tion of male labour mi­grants, which is es­ti­mated at a stag­ger­ing 505,728, ob­vi­ously trans­lates into a large num­ber of peo­ple liv­ing with HIV”. Nepal still has a long way to go – and a lot of work to do. ag

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