Ensnared by AIDS. David K. Beine
authors have focused on the impact of “modernization” and paradigms of Western development upon the Nepali medical systems (Adams 1998; Justice 1986; Pigg 1992, 1995a, 1995b, 1996; Stone 1976). Focusing on the impact of the application of Western paradigms for primary health care programs in Nepal, Stone (1992) describes how Nepal has begun to favor a “community participation” approach to primary health care. The result has been a shift from curative services to an emphasis on health education. Although many aspects of this shift have been positive for Nepal, Stone illustrates that it is actually the underlying development discourses rather than issues of efficacy that have informed the community health program in Nepal. She cites critics that contend that the new approach (community participation) is simply another hegemonic Western device, which “promotes current political and economic structures of inequality” and she concludes that “the current focus on community participation appears to be an attempt to promote the Western cultural values of equality and self-reliance (values not shared by the local population), while ignoring alternative values and perceptions of how development might work in rural, non-Western societies of developing countries (Stone 1992:412).” Stone (1986, 1992) also demonstrates how, ironically, this new mode of thinking (with its emphasis on community participation) actually stifles the voices of the local people rather than taking them into account.
Likewise, Pigg (1995b:47) demonstrates how many principles inherent in Western development paradigms and discourses being deployed in Nepal “systematically dismantle and decontextualize different sociocultural realities in the course of taking them into account.” Similarly, Justice (1986) demonstrates how Nepali health planners, even if they have social and cultural information available, do not use it in health planning. She suggests that this is largely due to deference on the part of national health planners toward the favored paradigms of international aid bureaucracies.
Pigg (1996:161), further illustrating the impact that Western development discourses (which dominate health development approaches in Nepal) have had, demonstrates how traditional healers (shamans) have been “caught up in the meanings of modernity.” Bikaas ‘development’ is perceived as good and anything traditional (such as shamanism) is seen as backward. Likewise, Adams (1998) demonstrates how Nepali doctors, favoring a paradigm of Western modernity, were instrumental in the recent democracy movement. According to Adams, Nepali doctors, who see themselves as modern individuals (which implies an understanding of modern medical science as objective “truth”), have served as harbingers of Western epistemological hegemony in the politicization of medicine in Nepal. She contends that the democracy movement was a product of individualism, which itself was largely the result of Western paradigms implemented by health planners in Nepal.19
All of these authors illustrate the impact that Western discourses of development have had upon the Nepali medical systems. This issue will be revisited in the following pages as we consider the impact of the concept of bikaas upon the HIV and AIDS epidemic in Nepal.
Topography and economy (which are related) combine to make health care services generally poor in rural Nepal. Add to this the pluralistic nature of the Nepali medical systems and one is left with a system that has affected, and will continue to affect, the spread of HIV and AIDS in Nepal. This will be discussed further in the coming chapters.
1.8 Religion
As can be seen, there is a strong tie between medical practices and religion in Nepal. The current census of Nepal (NPHC 2012) lists 81 percent of Nepal’s population as Hindu, followed by 9 percent claiming Buddhism, 4 percent Islam, 3 percent Kirat, 1 percent Christian, and less than 1 percent each following Prakriti, Bon, Jainism, Bahai and Sikhism.20 These figures are often debated and it is suggested that the numbers of non-Hindus is actually much higher (Pfaff-Czarnecka 1997). Many of the mountain populations counted as Hindu actually practice a “Hinduized” animism or shamanism, which is heavily influenced by the ancient Bon religion of early Tibet.
A key feature of the dominant Hindu philosophy is the caste system. Modeled on the orthodox Brahmatic caste system of India, this system creates social classes and social stratification throughout all of Nepali society. According to Stone (1997:86), Nepali castes are “ranked status groups, with the ranking sanctioned by religion. The whole system is expressed through Hindu religious ideas concerning purity and pollution: Higher castes are considered more pure than lower castes.”
Stone presents a model of Nepali caste that posits sacred thread-wearing priests (Brahmans) at the top, followed by the sacred thread-wearing non-priests, the liquor drinking castes and the untouchable castes (fig. 1.2). Each of the castes has strict dietary and behavioral rules and interaction between castes is sanctioned by these rules (Stone 1997:86). And the most important rule is dietary: higher caste members cannot eat rice (or any food) cooked by persons of a lower caste (although the reverse is allowable). Many of the Tibetan, Tibeto-Burman and Muslim people groups of Nepal (all non-Hindu groups) also practice their own caste hierarchies.
| Pure | Sacred thread–wearing | Priests | Brahmans |
| ↑|||↓ | Non-priests | Chetris, etc. | |
| Liquor drinking | Matwalis | ||
| Impure | Untouchables | Various castes |
Figure 1.2 The Nepali caste system (adapted from Stone 1997).
The concepts of purity and pollution (which are at the core of the caste structure) will prove an integral part of cultural schemata (which underlie cultural models), as we will see in later chapters. As mentioned earlier, one’s caste standing has traditionally determined access to education and employment, which has implications for the spread of HIV and AIDS. AIDS is viewed by some as a problem only for the impure low caste. In chapter three we will be introduced to other aspects of religion that may also prove detrimental to the spread of HIV and AIDS in Nepal.
1.9 Conclusion
Many aspects of Nepal’s history, economy, geography, education and religion are linked to HIV and AIDS in Nepal and have played a part in fostering the spread of the disease. The impact of these various societal features will become evident when we consider the HIV and AIDS situation in Nepal further in chapter three. We will also see in later chapters that many of these same societal features have been influential in shaping cultural models of HIV and AIDS and their underlying illness schemata. Before we address HIV and AIDS specifically in Nepal, it will be helpful first to examine the topic of HIV and AIDS generally. This will be the focus of the next chapter.
2 : AIDS
Nobel laureate David Baltimore, in a statement made at the American Academy of Arts and Sciences, said, “AIDS is a medical problem: The only issue is when we will solve it.”21 This represents one extreme view of AIDS, namely that it is purely a medical problem. At the opposite extreme there are those who suggest that the concept of AIDS is purely invented (Duesberg 1996). Others, taking a middle ground, recognize the biomedical reality of HIV (the virus that causes AIDS) but also recognize the social aspects involved in the construction of cultural meaning that is associated with the worldwide pandemic known as AIDS.
The one extreme position claims that AIDS is not real: it is a total “cultural construction,” the product of Western modernity wrapped in the narratives and discourses of the science of the modern era, only a “fact” as viewed through the narrow epistemology of Western medicine. I do not go this far. Although this type of Foucaultian postmodern analysis has its value in challenging the over-reified view of all science as “truth” (i.e., objectively removed from all social influence), for the people of Nepal, AIDS is a reality—a terrifying reality. I take the middle ground: AIDS is a combination of biological reality (the HIV virus) and social construction (the meanings associated with AIDS). Or, as Treichler (1992) has aptly put it, the problem is medical, the drama is human.
Human beings view disease in the context of biological and social conditions (Fee and Fox 1992:9). AIDS is a particularly good example of the social construction of disease. In the process of defining both the disease and the persons infected, politics and social perceptions have been embedded in scientific and policy constructions of their reality and meaning.
The purpose of this chapter is to briefly introduce the reader to the biomedical “facts” about AIDS, including its