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 causes, history and treatments, as well as to discuss AIDS as a social construction. Much has changed in the realm of HIV and AIDS since the first edition of this book appeared in 2003. Beyond the change of vocabulary (from HIV/AIDS to HIV and AIDS), new treatments are now available and there is even talk of a potential “cure” on the horizon. At the time of the first edition of this book, due to the emergence of antiretroviral therapy (ART) treatments and the subsequent first-time declines in associated death rates in the late 1990s—at least in the West—many (including myself) were just beginning to challenge the popular “dire predictions” narrative of the preceding decade.22 Because of the unequal access to these drugs, however, and with no foreseeable cure in sight, many (again including myself) expected the AIDS epidemic to continue relatively unabated outside the west, and certainly in Nepal, into the foreseeable future. What we couldn’t see at that time was the possibility of treatment as prevention and the emergence of possible “functional cures” that lay just around the corner. Given the recent developments of ART treatment as prevention and perhaps “functional cures,” many scholars believe we may be at a significant “turning point” in the HIV and AIDS epidemic. These recent developments will be discussed further in this chapter.
2.1 AIDS as biomedical fact
AIDS is the acronym used for the medically defined acquired immuno-deficiency syndrome. In lay terms, the acronym can be explained in this way:
Acquired: the virus is non-hereditarily transmitted23
Immunodeficiency: the virus weakens the immune system, resulting in greater susceptibility to various opportunistic infections24
Syndrome: a collection of common symptoms or signs (usually opportunistic infections) appears, which are fairly typical in infected persons.
AIDS is caused by a group of related viruses referred to as HIV (human immunodeficiency viruses).25 HIV, like most other viruses, requires reproduction within the cells of the body. Once inside the body, the virus attaches itself to the surface of T-cells (T-lymphocytes), commonly referred to as white blood cells. The virus then enters the host cell by attaching itself to a protein known as a CD4 receptor in the plasma membrane of the cell. When HIV comes in contact with the CD4 receptor, the cell opens up, letting the virus enter the host cell.
A defining characteristic of retroviruses (which include HIV) is that they are able to transcribe RNA into DNA (through the use of a special enzyme called reverse transcriptase), allowing the virus to integrate into the host DNA of the cell nucleus.26 Thus, HIV becomes resident in the cell nucleus by inserting itself into the infected person’s own DNA and grows in the body as cells divide and multiply. Cell reproduction takes place in the normal way (divide and multiply), but the newly emerging T-cells, which usually are involved in fighting infection, are compromised. T-cells are involved in attacking infected cells in our bodies. The HIV-infected T-cells, however, lack this ability, reducing the effectiveness of the body’s immune system. As the number of these HIV-infected T-cells increases in the body, the immune system becomes more and more depressed,
