Ensnared by AIDS. David K. Beine
have a positive reputation and can be found all over the subcontinent. In short, Nepal has a historical tradition, or culture, of migration. Although this tradition has always been rooted in the search for better financial opportunity, it would be a mistake to assert that poverty has been the catalyst for all people to migrate. Much of this migration has traditionally taken place from areas that were self-sufficient and where poverty was not a severe problem as it was elsewhere in the country. Many Nepalis have found a way to fill a foreign niche that has boosted their families’ economies tremendously. Unfortunately, this culture of migration results in faithful housewives (now the largest category of HIV suffers) bearing the brunt of the remaining epidemic in Nepal (as earlier statistics reveal) as well as facing the strong stigma that still remains associated with HIV and AIDS in Nepal (Beine 2011).
Many of the Tibeto-Burman cultures of Nepal’s mountainous regions also have traditionally practiced a semi-nomadic lifestyle. Seasonal migration has traditionally been a major feature of their culture as they brought salt from Tibet and traded it in India. Savada (1991:70) claims that these groups “historically were deeply engaged in interregional as well as cross-border trade with Tibet as their principle economic activity.” Again, for many of these groups, migration is a historical, chosen economic strategy that provides an above-average standard of living rather than a supplemental income-generating strategy designed to alleviate poverty. Dahal (1994) makes this assertion among the Byansi, a semi-nomadic group in far-Western Nepal. Nepal’s indices for measuring poverty usually include such features as land ownership, development of infrastructure, and availability of basic social services. Using this standard, the Byansi people are very poor. Dahal (1994:37), however, contends that they are actually one of the most prosperous peoples in the whole region. He claims that this is because “the conventional measurement of ‘income’ is unable to capture the diversity of local resources and their cultural modes of exploitation” (1994:36). Although it is clear that for many, migration is an economic strategy necessitated by low yields and growing populations, for others it is a tradition that has supplied economic abundance.
There is also a cultural tradition of drug use in Nepal. Shrestha focuses upon elements of Nepali culture that facilitate the use and abuse of drugs and alcohol. These include a historic cultural acceptance of alcohol use, recreational cannabis use by the elderly, and religious cannabis use by holy men (and distributed by the government for this purpose) (1992:1241–1242). IDUs have been identified as the second largest risk group for contracting HIV and AIDS in Nepal and although the issues need to be examined more closely, poverty does not seem to be the main cause pushing people into drug use. In a recent study among IDUs it was determined that the majority were highly educated and financially self-sufficient, earning well above the national average (Maharajan et al.1994).
Except for cases in Nepal where HIV is transmitted through drug use, HIV is spread mainly as a result of sexual transmission. In the earlier edition of this book I wrote much about the public or conservative versus the supposedly private or promiscuous nature of sex in Nepal. I concluded (based mainly on the existing literature) that “there has long been a tradition of premarital and extra-marital sex in Nepal” (2003:87). I used the writings of authors such as Cox and Suvedi (1994) who have “noted that ‘among young unmarried men the use of FSWs is well accepted’” and authors such as Smith (1996) and Gurubacharya and Suvedi (1994) to conclude that, “contrary to the portrayal of Nepali society as sexually conservative, premarital and extramarital sex is not uncommon.” I added anecdotal evidence from my own informants (all HIV positive): one who told me, for instance, of the “‘custom’ of being taken (by older friends) to a prostitute when ‘coming of age’” in a kind of “‘sexual initiation’” that is “not uncommon among Nepali boys”; and another who said that “promiscuity is expected among young men—Nepali men are assumed to be unfaithful,” to strengthen this working hypothesis. I concluded that “sex may be a taboo topic in Nepal…, but, as various authors have demonstrated, just because people are not discussing it doesn’t mean it’s not happening” (Beine 2003:87).67
In recent years, however, because of my studies and experience in Nepal, I have begun to doubt the veracity of such claims being normative among the wider society. Green, Farley, and Ruark have concluded that “national surveys in Africa and Asia repeatedly show that a majority of unmarried teenagers practice abstinence and that a majority of adults practice faithfulness to one partner in any given year (Green et al. 2009). Nepal seems to be no exception to this. For example, in a study of 573 male college students in Nepal, 61 percent report being abstinent (Adhkari and Tamang 2009). In a study of young factory workers in Kathmandu, 80 percent of young boys and 88 percent of young girl factory workers report being abstinent (Puri and Cleland 2006:237). In a seven district survey of Nepali teenagers done by UNAIDS and UNICEF, 78 percent of the boys reported no premarital sexual experience. And in another study of male adolescent students, 53 percent reported intent to remain abstinent until marriage (Iriyama et al. 2007:64). Interestingly, each of these studies (except the last) were all framed in the negative rather than the positive (as I have done above); that is, they only reported the percentage of sexually active (which was 39%, 20%, 12%, and 22%, respectively) and made comments regarding this data, such as, “These studies indicate a growing trend toward premarital sexual activities among adolescents,” “showed risky behavior especially among boys,” etc., and yet no comparative data is given to support these claims (Adhikari and Tamang 2009:242). Another study (Puri and Cleland 2006) states that “despite religious and cultural restrictions, one in five boys and one in eight unmarried girls reported experience of sexual intercourse,” and that “early sexual experimentation and low and irregular use of condoms are not uncommon.” Don’t these numbers actually show that the majority of unmarried adolescents are practicing abstinence? I don’t know how these authors would define “uncommon,” but if only two in ten boys is sexually active (which actually seems low to me), then early sexual experimentation is not common, although I am left with the impression that it is, based on the use of this negatively framed language. The same trend continues in the literature today. Regmi, Simkada and van Teijlingen (2010:61), citing many of these same sources, similarly concluded that “despite these generally traditional views [regarding sex] a significant proportion of young people are engaged in premarital and high risk-sexual activities.” Is there an ideology undergirding these perceptions? This is an issue I hope to address in a forthcoming publication. So while premarital sex is certainly not unknown, neither is it “common.” As I have reassessed, I would take a more middle ground position. It is not as conservative as publically presented and not as promiscuous as other authors would suggest. There also seems to be a growing rural and urban divide (including western sexual values) that accompanies urbanization. I will talk more about the implications of this later as I address prevention strategies.
In conclusion, it seems clear that the spread of HIV and AIDS in Nepal is due to a combination of complex factors. Structural factors, issues of agency, and culture are all involved in creating casualties and have extracted a high price.
3.2.4 KAP studies
Much of the social research conducted on HIV and AIDS in Nepal has been in the form of knowledge, attitudes, and practices or behavior (KAP or KAB) studies.68 The majority of the findings above (concerning the cultural factors that contribute to the spread of HIV and AIDS) are, in fact, the result of such KAP or KAB studies. This type of study is a product of the Health Belief Model69 and the Theory of Reasoned Action (Tones 1994) that posits lack of awareness as the primary factor contributing to the spread of disease, and education as the primary weapon to fight it. As will be seen later, Nepali policy planners, informed by this Western applied anthropology perspective, made “awareness-building” the major focus in Nepal’s first prevention strategies and programs. Since lack of awareness is reasoned to be the primary factor contributing to the spread of disease, and education is viewed as the primary weapon to fight the spread of disease, resultant prevention programs developed from this theoretical paradigm tend to give primacy to “awareness-building.” For instance, one KAB study done in Nepal concluded that “the most effective strategy to reduce the spread of the epidemic in the short term and protect women is to raise the awareness amongst the men” (Smith 1996:i).