COLUMN ONE : Facing Peril of AIDS in Nepal : The Himalayan kingdom is fertile ground for HIV. Health workers try to counter a deeply ingrained sex trade, rooted in poverty and a caste society that treats women harshly.
In the antiseptic parlance of public health professionals, Amarwati is a “commercial sex worker” and potential “vector” for AIDS.
Two or three times a day, the 21-year-old woman with black curly hair and a nervous smile brings men into her modest home with stained yellow walls, and steers them toward a hard wood-frame bed.
As a fan overhead whips the warm air, she and her clients have sex.
She earns $2 to $3 daily. Amarwati, who has an 8-year-old daughter, is not unusual. So many women in her district of this lowland town in midwestern Nepal are prostitutes that a patch of dusty ground across from their homes seems, like a freakish garden drawn by Salvador Dali, to have bloomed with a crop of used, shriveled condoms.
Amarwati and her neighbors are among the reasons that officials in this small landlocked kingdom, renowned for its snowy Himalayan vistas and exotic culture, are now bracing for the onslaught of the human immunodeficiency virus, which causes AIDS.
“All symptoms point to the fact that when HIV begins to spread with velocity here, it will explode,” said Dr. Daniel Tarantola, director of the International AIDS Program at the Harvard School of Public Health’s Francois-Xavier Bagnoud Center.
Nepal’s looming crisis is part of a general, alarming trend. Last winter, the number of HIV-infected people in south and southeastern Asia overtook the total of infected people in the industrialized world for the first time, according to a study published this year by Harvard’s Global AIDS Policy Coalition.
Judging by available evidence, the study concluded, the number of people who are infected yearly with HIV has begun to decline everywhere--except in Asia.
The trauma and challenges of AIDS, whose first cases were recognized among gay American men in 1981, are unfortunately not new. But as health professionals are learning, dealing with HIV as it speeds through previously uncontaminated societies requires much more than duplicating approaches used in the United States, Africa or elsewhere.
Take Amarwati. Since she was 12 and her family desperately needed money, she says, she has been engaging in prostitution. Her mother did too, she says.
Both women belong to the Badis, a branch of the despised Hindu caste known as the Untouchables. Badi women have traditionally sold their bodies. An estimated 15,000 to 16,000 members of the subcaste live in Nepal, and 40% of their households contain at least one woman engaging in the sex trade, experts say. Each sex worker may support up to eight family members.
With an entire community dependent on prostitution for much, if not most, of its income, eliminating Badi women as potential HIV vectors, or carriers, is difficult. Handing out more than 7,000 condoms each month to the prostitutes and teaching them and customers how to use them with cartoons on a flip chart, as the grass-roots Social Awareness for Education (SAFE) does in Nepalganj, is just a start.
“Our purpose is also to supply an alternative profession for the Badi people,” SAFE leader Dilip Pariyar said.
It’s a mighty, uphill struggle, and one emblematic of the social changes that specialists like Tarantola, a garrulous, charming Frenchman who received a prestigious Albert Schweitzer Award for his achievements in public health, say must be made in tradition-bound Nepalese society if AIDS is not to spread like wildfire.
In this beautiful but impoverished land, where the average annual income is $165, the economic lure of prostitution is strong, especially if a woman knows no other trade. In many villages, it is assumed that any hut that has a tin roof instead of a thatch one houses a prostitute who can afford the more expensive covering.
Many Nepalese, reared in the traditional Hindu value system that regards each caste as fit for only one type of labor, have a difficult time imagining Badi women engaged in anything but sex for hire. That is one reason that SAFE has opened a hostel in Nepalganj for 22 Badi girls, ages 8 to 17.
The youngsters, freshly scrubbed and wearing white smocks, used to live at home, but relatives who wanted to act as their pimps--as well as hopeful clients--wouldn’t stop soliciting them, Pariyar said.
The Badis represent only a single aspect, albeit a unique one, of the challenges facing Nepalese and foreign organizations wrestling with the AIDS crisis here. By some estimates, a staggering 200,000 Nepali women are employed in brothels in India. Some went willingly, while others were duped by brokers who bought them from their parents.
This Indian sex trade may represent the greatest potential AIDS carrier of all. In Bombay, where an estimated 60,000 Nepalese women toil in the brothels, nearly 45% of prostitutes have tested HIV-positive.
What will happen when these Nepali women return home, often to isolated mountain hamlets where there is no AIDS testing? And what of their clients? An estimated 90,000 Nepalese men work in Bombay, and a fact-finding mission this year by Nepalese women’s organizations to 50 Indian brothels found that a Nepalese prostitute, on average, “entertained” four or five countrymen every day.
“These men then come home to their wives and families,” said Dr. Renu Rajbhandari, executive director of the Women’s Rehabilitation Center in Katmandu, the capital. “And we don’t know how much HIV they are bringing back.”
The cross-border trade in prostitutes, most of whom are taken to India when they are 12 or 13 and treated as sex slaves, could have devastating consequences for the Tamangs and other hill tribes of central Nepal, whose women and girls are particularly prized by men in India and other parts of Nepal for their docility and gentleness.
“From Nuwakot, the girls go because they need money. They don’t have anything else,” Rajbhandari said. In the villages of another central district, “you can’t find a young woman,” she added. “They are all in Bombay.”
To minimize the women’s risk of contracting HIV or venereal disease, the Women’s Rehabilitation Center has hired half a dozen Bombay prostitutes to work as “peer counselors” in the brothels, responsible for explaining the hows and whys of AIDS and condoms, which many Nepalese have never seen.
“We can’t say, ‘Don’t do prostitution,’ ” Rajbhandari said. “This is not our right. We say, ‘Have safer sex.’ ”
But with as many as an estimated 90% of the girls from some villages in Sindhupalchok, north of Katmandu, engaging in prostitution, the Women’s Rehabilitation Center is also trying to promote alternative income projects, like bamboo crafts, to break the economic logic that causes many women to opt for or be ensnared in the sex business.
“If they can earn 700 rupees (about $15) per month, they won’t go to Bombay,” Rajbhandari said.
At WRC headquarters, 15 girls and young women make a living knitting sweaters, which a middleman buys for $5 apiece for shipment to Germany. One star knitter is Gita, 28, who was sold into prostitution by her cousin, but who had to return to Nepal from Bombay when a blood test showed she is HIV-positive. Now sometimes brooding and temperamental, Gita says she has a lover and wants to get married.
As in sub-Saharan African countries, poverty is a contributing factor to the spread of AIDS here. Dr. Benu B. Karki is chief of the Nepalese government’s National AIDS Prevention and Control Project. He has a staff of 15 and an annual budget of $300,000 for a nation of about 20 million people.
“Raising awareness is the only strategy that we have in the AIDS program,” the harried doctor said. “I don’t have any regional, district or village staff.”
Nepal’s conservative Hindu mores also complicate the anti-AIDS campaign: Outside of marriage, people generally don’t talk about sex. A woman is not deemed a man’s equal and has little or no control over her sex life.
And in a country where 74% of adults are illiterate, prudery and ignorance seem to reinforce themselves.
“If you want to examine a person’s private parts, either they refuse, or they leave the doctor’s office,” Karki said. “We really don’t find out about some people (AIDS victims) until they die.”
The first AIDS case in Nepal was diagnosed in July, 1988. Today, Health Ministry statistics say 100 men and 102 women have been found to be HIV-positive. Thirty of them have developed AIDS, and 15 have died.
Extrapolating from those numbers, the ministry estimates there are 6,000 HIV carriers in the country. But Karki admitted, “We really don’t know the situation.”
Other potential AIDS carriers include about 350,000 Nepalese who head to India each year in search of work. “They are uneducated and don’t even know what a condom is,” Karki said. In the other direction, an estimated 2 million truck drivers, farm workers and other Indians flock annually to Nepal, where they often patronize prostitutes.
To supplement the government’s modest anti-AIDS effort, a number of local and foreign charities and nonprofit organizations have stepped in. AmFAR, the American Foundation for AIDS Research chaired by actress Elizabeth Taylor, began funding 17 prevention programs in Nepal in October and says it will pump more than $600,000 in grants and technical assistance into the country annually for three years.
“Our strategy is to go to countries with low incidence of HIV, but where there is danger of rapid growth,” said the Rev. Margaret R. Reinfeld, an Episcopal priest who is AmFAR’s director of education and international programs. “We try to encourage community responses in ways appropriate for those countries, and not import ready-made solutions.”
This has taken the anti-AIDS message in some strange directions that do not always meet with full approval from the American donors. This summer, members of an AmFAR delegation cringed as one of Nepal’s oldest social-service organizations, Agroforestry, Basic Health & Cooperatives Nepal, distributed brochures at a Bhaktapur elementary school that were intended to inform children about AIDS.
The leaflets contained graphic, colorful photographs of sores and other symptoms. Although the youngsters eagerly scrutinized the pictures and listened politely to the teacher, some clearly didn’t understand the significance of the lesson.
“But why do we need a sexual partner?” one asked.
Funded wholly or in part by AmFAR, social workers now cruise Katmandu’s “Freak Street,” a rendezvous made famous by Western hippies of the 1960s, and exchange needles used by some of Nepal’s officially estimated 25,000 intravenous drug users, most of whom shoot low-grade heroin. At the country’s biggest cracker factory, a traveling lecture session and burlesque street show in June told workers and neighbors about AIDS.
There was even a how-to lesson on condoms that erupted into general hilarity when a hapless male assistant inadvertently launched the condom into the air.
In Nepal, the anti-AIDS message is being preached by community organizations that, in addition, promote growing leafy green vegetables to reduce Vitamin A deficiency, goat husbandry as a means to financial independence and the buying up of land to distribute to impoverished tribes or castes.
There seems to be a clear danger that information about AIDS will be drowned out by other items on the agenda. But Tarantola insists that this community-based approach is the only effective strategy. And though some anti-AIDS measures may seem to have little in common with, say, the activities of the Gay Men’s Health Crisis, the root logic, Tarantola said, is identical.
“I suggest that wherever discrimination exists . . . this is probably where the highest vulnerability for HIV is,” said Tarantola, scientific editor of the voluminous “AIDS in the World” study. “You can correlate marginalization with vulnerability.”
In Nepal, “marginalization” means the situation of groups like the Badi. It is too early to foretell the fate of Amarwati and her neighbors. One recent study found that 70% of Badi sex workers suffered from syphilis and other sexually transmitted diseases, but HIV apparently has not yet made significant inroads.
So perhaps the Daliesque landscape of castaway condoms in Nepalganj’s Badi ghetto is a sign of hope. As a result of advice from SAFE’s health workers, Amarwati says, for the past 12 months she has insisted that her clients use a condom. If necessary, she can provide one.
“If they use a condom, they get it,” the Badi woman said matter-of-factly. “If they don’t, they don’t. It’s my health.”