Ensnared by AIDS. David K. Beine

shared with me their stories. May the details of their lives that make up this book bring about a solution to the looming problem of HIV and AIDS in Nepal.

Abbreviations

      AIDS Acquired Immunodeficiency Syndrome

      ART Antiretroviral Therapy

      CDC Center for Disease Control

      CMA Critical Medical Anthropology

      FHI Family Health International

      FSW Female Sex Worker

      HIV Human Immunodeficiency Viruses

      HSCB HIV and AIDS and STI Control Board

      IDU Injecting Drug User

      INGO International Non-governmental Organization

      IOM Institute of Medicine

      IS Idiosyncratic Schemata

      KAB Knowledge And Behavior

      KAP Knowledge And Practices

      MARP Most At Risk Population

      MCP Multiple Concurrent Partners

      MDP Millenium Development Goal

      NAC National AIDS Council

      NACC National AIDS Coordination Committee

      NAP National Action Plan

      NCASC National Center for AIDS and STD Control

      NSP National Strategic Plan

      PEMA Political Economy Medical Anthropology

      PEPFAR President’s Emergency Plan for AIDS Relief

      PIMS Primitive Innate Mental Schemas, or universal schemata

      PLHIV People Living with HIV

      PWA Person with AIDS

      PLWHA People living with HIV and AIDS

      SAE Semi-autonomous Entity

      STD Sexually Transmitted Disease

      STI Sexually Transmitted Infection

      USAID United States Agency for International Development

      VDRL Venereal Disease Research Lab

Part One : Background and Theoretical Underpinnings

1 : Nepal

      MAP Figure 1.1 Map of Nepal, map no. 4304, January 2007 (United Nations Publications Board, used by permission).

      Many aspects of history have played a part in formulating and fostering the current AIDS situation in Nepal, including population demographics, economy, geography, the educational system, medical systems, and overriding religious philosophy, as well as the current political structure. Because of the relationship of these factors to the current AIDS situation, they are introduced in this chapter.5 Nepal is a small, landlocked nation sandwiched between Chinese-controlled Tibet and India (fig. 1.1). With a population of 26.6 million (Central Bureau of Statistics 2012), the country of Nepal is best known for its legendary Himalayan mountain range. It boasts nine of only fourteen mountains in the world over eight thousand meters (26,247 feet), including the tallest, Sagarmatha (the Nepali term for Mt. Everest). The country also claims tropical jungles (currently being lost at an alarming rate) which are home to Bengal tigers, elephants, and rhinoceroses. The diversity of landscape mirrors the collage of cultures. The country is home to more than a dozen cultures—each with its own language, with multiple dialects, from three major ethnic groups,6 which have settled over thousands of years, through sequential historical migrations (Savada 1991; Anderson 1987).

1.1 A brief history of Nepal

      1.1.1 Pre-history: ?–500 B.C.

      Archaeological finds from the Neolithic era demonstrate that this region was occupied, but little is known about these early settlers. Legends suggest that they were the cow-herding Gopals or Ahir tribes, but this remains to be confirmed by archaeologists.

      1.1.2 Ancient Nepal: 500 B.C.– 700 A.D.

      The first historical inhabitants of the Kathmandu Valley were the Kirati, a people of Mongolian origin following a proto-Hindu religion.7 The Kirati settled the Kathmandu Valley and established small settlements with limited central authority. These eventually grew into a powerful kingdom that saw the reign of twenty-nine kings. The kingdom was economically strengthened by trade with countries as far away as Sri Lanka and was at its zenith in the fourth century B.C. Then the Khasa, pastoral Aryan tribes who had migrated into northwest India between 2000 and 1500 B.C., began to slowly inhabit the Terai region, which today is part of Nepal. These tribes (following a Vedic Hindu religion) grew into confederations of tribes or small kingdoms that were often at war with one another. From one of these small kingdoms of the Terai came Prince Siddhartha Gautama (the Buddha), whose followers and missionaries carried the new Buddhist religion as far as Mongolia to the north (crossing Nepal and Tibet en route) and Sri Lanka to the south. Buddhism was established in the Kathmandu Valley and throughout most of Nepal. It added unique features to the Kirati and Khasa cultures of modern-day Nepal such as a belief in the divinity of the monarchy.

      About 300 A.D. the Licchavis (a Khasa tribe from northern India) invaded Kathmandu, driving out her Kirati population. The Kirati were pushed to the east where they settled in the hills as simple farmers. Today’s Rais and Limbus (two of Nepal’s indigenous groups) trace their ancestry to them. The Licchavis invasion brought with it one of the most significant and lasting changes to Nepali culture, namely the Hindu caste system. The Licchavis dynasty was centered in Kathmandu but its widespread roaming armies managed to produce the first true Nepali state. It is also certain that the Licchavis looked back to their Indian homeland, which exerted a powerful cultural influence upon the people of Nepal, especially in terms of their Hindu religion (which was syncretized with the established Buddhism and leftover animism) and art. By the end of their dynasty in 750 A.D., the political system mirrored that of the Rajas of India: they were absolute monarchs in theory but actually interfered minimally in their subjects’ lives due to the mountainous geography. The economy during the Licchavis dynasty was based mainly on agriculture. The king established a system of hierarchical political leaders that descended to the local level while it allowed the dynasty to maintain control of the wider area. This political system would later (i.e., in the late twentieth century) serve as a model for the political development of modern Nepal. The Licchavis also continued the tradition of trade with Tibet and India (including the export of Buddhism with the marriage of one of her Licchavis princesses to the king of Tibet, whom she converted).

      1.1.3 Medieval Nepal: 750–1750

      Around 750 A.D. Nepal began to enter what some have called its “Dark Ages,” about which little is known. It seems there were constant struggles among prominent families and royal lineages (still all Rajputs) for the throne, and leadership changed several times during this period of instability. Kathmandu was also invaded twice by growing foreign powers during the early years of this period (Tibet in 705 A.D. and Kashmir in 782 A.D.), but both attempts proved futile. The most profound change upon Nepali culture that can be traced to this time period is the move away from Buddhism on the part of the kings toward a stronger Vedic-Hindu devotion.

      In 1200 the Mallas (Khasa groups who had ruled kingdoms in Rajasthan from the early 600s) began to inhabit Nepal and (perhaps through marriage or political struggle) assumed the throne. The rule of the early Mallas was far from peaceful. North-Indian Malla kingdoms plundered Kathmandu five times between 1244 and 1311. Worse, an earthquake devastated the valley in 1245, killing a third of its populace. Meantime, Hindu kingdoms of northern India were being broken up by the invading Muslims, sending waves of Hindu migrants into Nepal who established dozens of tiny hilltop kingdoms (forty-six in west and central Nepal). A rival Malla kingdom from western Nepal also attacked Kathmandu six times in an attempt to gain control and the city was invaded in 1345 by Muslim