Nepalese Culture Essay Paper

Keywords

HIV/AIDS, culture, antiretroviral, adherence, Nepal

Introduction

Culture is defined as the system of values and norms shared by a group or society or that shaped by social knowledge [1] . It is the collective consciousness - a way of acting, feeling and thinking by groups of people and shaped by a sense of shared customs, knowledge, beliefs and perceptions that define individual behaviours. So it is described as social glue [2] and commonly held in individual and group perceptions. Thus, culture involves a larger group of individuals which is a socially constructed phenomenon, a human product, and is shaped by people belonging to various groups [3] .

Individuals are socialized into society by being taught and learning the behaviour and belief patterns that deal with human systems. It consists of the unwritten rules of social relationships with the collective programming of the mind, which distinguishes the members of one group of people from another [4] . It is a pattern of shared basic assumptions which is invented and developed within a society or group that has worked well enough to be considered applicable to diverse communities with different values. Therefore, it is taught to new members of the groups as the correct way to perceive, think and feel in relation to those problems [5,6] .

The way people make sense of illness is in part culturally determined. Existing beliefs and presuppositions shared by a cultural knowledge regarding illness play a significant role in shaping an understanding of newly emerging illness in any given culture [7] . Certain elements of culture tend to remain over time while others change, like negative beliefs and individual health practices such as side effects of ARV drugs rather than a positive outcome. How individuals make sense of their situation and share realities may become objectified with their everyday life [8] . Thus, cultural relativities affirm that one culture has no absolute criteria for judging the activities of another culture. However, every culture can and should apply such judgement to its own activities, because its members are actors as well as observers [4] . Social scientists argue that culture is learned, shared, transmitted intergenerationally and reflected in a group’s values, beliefs, norms and the practices of individual and family roles and other social regularities [9] . It is further explained that culture is a basic assumption and that beliefs operate unconsciously from generation to generation [10] . It is the purpose of this paper to investigate such emerging perceptions and to discover whether they have significant influence on treatment adherence in HIV/AIDS.

Methodology

Various electronic databases (Medline, Science Direct, Google and Google Scholar) of scientific literature and reports were accessed through the internet publications that looked at health, illness, HIV/AIDS, treatment and its relationship with the cultural factors (beliefs, religious practice and customs) of HIV/AIDS treatment and adherence to ARV medication. Various hard copies of related textbooks, scientific journal and relevant documents were also incorporated for the reverent topics, making use of a reference list of publications and citation searches.

Health beliefs and use of health care facilities in Nepal

Health and illness are not only physical conditions but are based on perceptual judgements. This may influence the health care choices and decisions to seek health services, trust between health care providers and the treatment regimen and even their actual physical responses to health care treatment [11] . These all have an intimate linkage between disease, medicine and human culture and the cultural perspective on the relationship of health beliefs.

How individuals make sense of illness

The word health is primarily associated with illness, disease and medical treatment which are all biological phenomena. Health and illness are not equal opposites, but health is disrupted by illness and medicine is the clinical application for disease [12] . Nepal is a multicultural and multiethnic society with over one hundred ethnic and caste groups [13] . But Nepalese health and illness beliefs may vary, attributing illness to biomedical, natural or supernatural causes or any combination of these different categories. These illness beliefs and practices have been influenced by many different sources throughout history. For instance, illness is believed to be caused by a “supernatural attack” and, in many cases, demons or witches are sometimes believed to be the cause of illness [7] . But it must be asked how common-sense guides our beliefs and behaviour towards other people [14] . Sense making is grounded in both individual and social activity as well as a process in which individuals develop cognitive maps (i.e. beliefs and behaviour) of their environment, i.e. illness caused by supernatural attacks [8].

Supernatural account of causes and treatment of illnesses

The notion of health is encouraged by a purely medical conception of health and illness. According to Dixit, Nepalese people are praying to various deities for protection from disease and illness, not only at times of stress but also for comfort and future wellbeing. There are specific deities to whom specific offerings are made; a particular purpose for one such as Bhatbhatini is for children frightened by sprits; Santaneswar/Gyaneswar mahadev is for infertility; bathing in Kumbeshwar is said to cure several skin diseases including leprosy [15]

Similarly, health and ill health can be attributed to one’s relationship with the spirit world of gods and anti-gods (demons). Attribution theory as formulated by Heider and used to frame beliefs and values may lead to particular patterns of behaviour. It links to a person’s perception about the intention and disposition of others and raises questions on how individuals interpret events and how this relates to thinking and behaviour [14] . A person seeking to understand why another person did something may attribute one or more causes to that behaviour [14,16] . These traditional beliefs and superstitions can explain illness in terms of religion or fate, prevent illness by properly attending to ritual, making promises to the gods, giving offerings, sacrificing animals or through prayer. It shows that health beliefs are related to causal explanations and that perceived risk seems to be especially influenced by attributions and is also related to locus of control [17] .

Some individuals may attribute certain classes of illness to be caused spiritually and others caused naturally. Illness is diagnosed and cured by Jyotisis (astrologers), Guru- Purohits (priests) or monks through prayers and to the Dhami and Jhankri (traditional healers), Gubaju [11,18] . Treatment is done by chanting mantras and shouting at the spirits to leave the person’s body, violent exorcisms in which the patient is burned, frightened and beaten until the spirits flee the patient’s body, and by giving offerings and sacrificing animals [11] . Faith healing has been one of the most significant health care systems in Nepal since early time [19] . An individual has the right to get medical services, diagnose their condition with respect to norms and prescribe drugs to return to normal life [20] . There is a question about how sense making is fundamentally concerned with this multiethnic and multicultural diverse Nepalese community towards health and illness [21] because health is an area of intercultural interference of individual perception of health concepts and attitudes to effective treatment.

Nepalese cultural issues in fuelling HIV/AIDS

Folk beliefs about effective treatment

Nepalese people perceive HIV/AIDS as a bad person’s disease, as a result of bad karma [works done in a past life that either earn merit (if good) or punishment (if bad) in present life] and the belief in a strong connection between worry and disease [7] . Thus, HIV/AIDS related sickness is perceived as a punishment for some wrong doing that has been committed. This shows that personal attribution is more likely than a situational one, that people can be punished and therefore that some control over that cause can be effected [17] .

Nepal is experiencing a spread of the HIV epidemic from high-risk behaviour groups (sex-workers, migrant workers) to the lowrisk behaviour population such as housewives [22] . Besides issues of personal choice there are also many widely held beliefs and cultural practices that are contributing to the spread of HIV/AIDS in Nepal [23] . Most of these are related to folk beliefs about prevention and treatment for HIV/AIDS, such as that having sex with 108 virgins will cure AIDS and STD, cleaning the penis with urine, Detol soap or Coke will cure AIDS and STD, Nag puja (festivals) will cure HIV, anal sex will cause HIV, HIV is prevalent only in Bombay and a tika from Sai Baba placed on the penis will cure STDs and AIDS [23] . Such faith in a higher power may help clients to make sense of their world and acts as a foundation for daily decision making. But if patients are more likely to follow treatment advice they perceive this to be a common-sense approach to maintaining their health [17] . Thus, it is important to find out whether or not such beliefs influence adherence to medical treatment.

Cultural norms - family/moral affront/social stigma

Nepalese culture is not open to discussion about sex and sexuality. For instance, Nepali people are bound by the culture of silence around sexual matters. Cultural values such as shyness prevent open discussion and education on sexuality. People dislike hearing and discussing such subjects among the family members. This can be illustrated by the experience of a radio program in Nepal, called “Chatting with my best friend,” that spread knowledge and awareness of HIV/AIDS. According to the programme producer, “the programme initially received many letters complaining about the discussion on use of condoms, sex and sexual organs” [24]

Since HIV/AIDS has been associated with prostitution, drug use and traditional ideas concerned with promiscuity, religious or moral beliefs lead people to believe that HIV/AIDS is the result of moral faults such as “promiscuity or deviant sex” and is considered as a bad person’s disease and the result of bad deeds in an earlier life, so they deserve to be punished. Sex workers and drugs users go against the moral and traditional customs [23,25] .

People living with HIV are often subject to stigmatization and discrimination and still this is a much talked about issue in Nepal [22] . It is noticed that stigma against HIV may be an obstacle to undertake preventive and treatment services. Fear of stigmatization and discrimination prevents people from accessing testing and seeking treatment services, which make them vulnerable to HIV/AIDS infection. The self stigma and hostility in people living with HIV/AIDS inhibits them from disclosing their HIV status and seeking medical assistance, therefore remaining in the shadows and so passing the infection on to others [23,25,26] . HIV infection is associated with behavior that is considered deviant. HIV related stigma and discrimination impedes every step in mounting an effective response for prevention, treatment and ultimately adherence to the medication.

Institutional prostitution

Nepal is a multi-cultural and multiethnic society. Its different cultures and castes have their own norms and values regarding sexual practices. Due to changing values and norms their unsafe sexual practices exist and people are increasingly vulnerable to HIV/AIDS [27] . There are certain cultural traditions in Nepal “that approve the sale of girls and prostitution” [23] ; these tribes are Badi and Deuki. Badi girls have their own thoughts and they have been involved in prostitution from puberty, continuing until they became too old [28] . Similarly, they do not use condoms and prefer “the desirability of pregnancy and creating more female sex workers within the family” [23] . The Badi became one of the archetypes of commercial sex work in Nepal and serve as an example of what has been variously described as religious, cultural or traditional prostitution as well as part of an evil tradition [29] .

Similarly, in far western Nepal, parents of Deuki offer their daughters to a temple deity in order to improve health, get a new job, bear a son or a number of other such reasons. The girls are unmarriageable, sex with a Deuuki is said to ensure eternal bliss [23] . There is danger in moralizing. Thus, there will be questions on how sense making is fundamental to accept the diversity and transformation of those diverse situations [21].

Position of women in society

Nepalese culture does not permit a female to make her choice in marriage and kinships practices vary across the different ethnic groups. Some ethnic groups of the Himalayan region practice polyandry (a woman is married to all the brothers in the family). Such fragility of marriage contributes to the risk of HIV infection in women. Nepalese women have limited decision making powers; they will be abandoned by their husbands and they are not allowed to make their own choices due to cultural or religious instructions on having sex, whether to use condoms, the number of children to bear. This and the preference of sons in society and in the family all make women highly susceptible to HIV infection as these limits control safer sex [30] . This traditional belief helps to make sense of the HIV/AIDS horror and it implies that individuals cannot be held responsible or accountable to overcome this over time [31].

Complicated treatment regimes

Life-saving anti-retroviral drugs (ARVs) help people living with HIV to have longer and healthier lives; however, low adherence seriously compromises the efficacy of this treatment [32,33] . Maintaining a high level of adherence over the long-term often proves difficult [34,35] . Although availability of adequate resources and health infrastructures (physical, human & financial resources) are essential for HIV prevention and treatment, they may not always be sufficient because human behaviour and beliefs are also critical elements. Personal experiences, social network attitudes and health beliefs interact with and influence health seeking behaviour. Inadequate knowledge of and negative attitudes towards ARVs, fear of side effects and complexity of regimens may all be significant barriers to prevent patients from undertaking treatment or maintaining adherence [36] .

Similarly, people insist on their cultural rights but there are a number of issues raised in HIV/AIDS treatment. Ethnicity and culture have multiple constructive and destructive roles for the promotion of ARV adherence [7] . Life-long and complicated treatment regimens as in the case of HIV are negatively correlated with a patient’s ability to complete ARV treatment. There is a big question about how and why people follow or deviate from the doctor’s prescribed medication. Adherence is a concept developed from the clinician’s (doctor’s) perspective. Cultural factors compromising adherence to ARV do not end with the influence of Nepalese existing knowledge, beliefs and practices, which are deeply embedded individual behaviours that can deter a patient’s inclination to take ARV medication.

Conflicts between traditional and western medicines

Nepalese beliefs make it distinctively challenging to practice traditional and western medical services in multicultural and multiethnic peoples in Nepal, although the western and traditional medical practices make it distinctively challenging and these philosophies are not always mutually exclusive. There can be serious interactions between conventional and traditional therapies and conflicting notions can negatively impact adherence to prescribed ARV medications [37] . Thus, Gill et al. stated that “if all structural barriers of adherence to ARVs are removed, ARV programmes can still fail if they do not adequately address the behavioural factors influencing adherence” [38] .

It is not unusual for clients who hold traditional cultural beliefs to consult traditional healers to treat the illness but this may impact negatively on their adherence to ARVs. An individual behavioural or cultural problem may constitute a further hindrance to adherence to ARV treatment.

Theoretical consideration: attribution theory and locus of control

Cultural factors (beliefs, perceptions and behaviour) necessarily influence the decision making process to seek health services. People seek different sorts of healers (faith healers or modern health) based on their perception and beliefs regarding the illness [11] . This makes it very challenging to distinguish individual behaviours from illness, i.e. seeking diagnosis and behaviours like adhering to a medication [39] . These both positive and negative health beliefs affect individual behaviour and perception. In order to understand these cultural issues and how they affect ARV adherence we must focus on theory of attribution and locus of contro [40] .

Attribution theory discusses how people make casual explanations about a variety of events and how those attributions motivate their behaviour. It creates complex models of common-sense attribution. Causal attributions are beliefs about what caused something to happen. They may attribute the cause of an event to factors which they believe are outside of their own control (i.e., luck or fate) rather than to their own control [14,17] . For instance, in adhering to a prescription for ARVs, a person’s attitude is expected to be determined by their beliefs about medicines; if the clients think ARVs are necessary, the individual is more likely to be adherent and if a client think that ARV drugs can be harmful, then non-adherence is more likely. The necessity of medication use is assumed to be determined by the severity of the symptoms, quality of life and the attributions of patients’ behaviours. But human behaviour is so complex that it cannot be explained through single concepts.

Thus, this individual human behaviour explains a social learning theory: locus of control. Locus of control refers to an attribution of responsibility for outcomes of internal versus external events. The locus of control dimension is linked most strongly to cause, such as efforts. It deals with the person’s beliefs, either internal or external factors. People believe their health is determined by internal or external factors; internal (information, ability) or external (fate, luck, opportunity or dependence on others) to the presence and is influenced by the person’s expectations of the outcome [17,40,41,42] . According to this approach, an individual’s state of health (or illness) is either a result of their own behaviour (health internal) or that their health is determined generally by such things as chance or other powerful factors over which they have poor control (health externals) [43] .

Specific behaviours where locus of control is relevant are seeking information, taking medication, making and keeping physician appointments and maintaining adherence to medication. Internals generally show more positive behaviours in each of these areas. The general assumption is for adherence to ARV medication. A person's attitude is expected to be determined by his/her beliefs about medicines. If the person thinks medicines are necessary, he/she is more likely to be adherent. However, if a patient has serious concerns about medication use and thinks that medication can be harmful then nonadherence is more likely [44] . However, this topic is unexplored in Nepalese context and is open for further research, particularly on adherence to ARV medication within Nepalese culture and its link to locus of control.

Impact of culture upon ARV adherence

Individual self administration of medication is an essential component of any disease management, because incorrect and incomplete medication can result in increased morbidity, mortality, healthcare costs and spread of drug resistance [32] . Adherence is considered as an individual management issue between patient (ARV receivers) and healthcare providers (clinicians) [37] .

Health service providers inevitably blame those beliefs and identify them as cultural barriers. Beliefs are often used as a proxy for culture. Biomedical perspective beliefs connote erroneous ideas that constitute obstacles to appropriate individual behaviour, because adherence to ARV medication is an individual choice. That’s why individual negative practices could be labelled as such because of their beliefs and behaviour and are often considered as barriers to the uptake of HIV treatment. It has become widely associated with negative individual health beliefs and practices which might be a reason for the poor uptake of HIV treatment [45] and it is this aspect that the present research intends to shed light on – the cultural aspect of adherence to ARV treatment.

The impact of beliefs and practices on adherence to ARV treatment have been numerous and significant and will continue to be so. The issue for providers is to attempt to meet the treatment goals within the patient’s beliefs about medicines and perceptions of personal sensitivity to the adverse effects of taking medicines. These factors may in turn limit the behavioural choices and uptake of services such as going for an HIV test (disclosure of status), beginning ARV treatment and then adherence to medication.

HIV/AIDS has been associated with sexual contact and with promiscuity. Religious or moral beliefs lead people to believe that HIV/AIDS is the result of moral fault such as “promiscuity or deviant sex” and is considered as a bad person’s disease and the result of bad deeds in an earlier life - so they deserve to be punished [23,26] . Such general perceptions may influence treatment preferences, pathways to care and adherence to medication because we are aware that HIV is a stigmatized disease and hence likely to remain a sensitive issue in Nepal [25] .

Societal negative attitudes and beliefs toward HIV/AIDS and its treatment, uptake and maintenance of adherence will directly affect the proposed study. For instance, HIV is a highly stigmatized disease and sensitive issue in Nepal; because of this, people may not want to participate in the study. People still do not openly discuss HIV and in general people believe that HIV is a bad person’s disease; in this sense ARV recipients (study respondents) may refuse to participate and discuss their personal behaviours and beliefs regarding adherence to ARV treatment.

Approaches to eliminate cultural barriers on ARV adherence

In all domains of practice, the service providers (doctor, nurse etc.) demonstrate skills and expertise not only in appropriate interventions, but also in their attitudes and beliefs about the value of the cultural context of the patient’s life. Individual health beliefs, perception behaviour and traditional values should be given due importance in order to maximize the adherence to ARV treatment. Historically, Nepalese health seeking behaviour is found to be mostly of a dual approach - traditional and western medicine. The effect of traditional medicine use on ARV adherence has not been reported yet. Traditional medicine use appeared to affect adherence negatively in Africa but we do not have any research in Nepal [46] .

In order to fully relate to another culture and to be sensitive to the patient’s beliefs and practice about their health seeking behaviour, a health care service provider must be aware of and sensitive to their own (clinician’s) culture. However, a culture-centred approach is required to adequately address the increasing number of HIV/AIDS cases in Nepal, because beliefs and perceptions influence individual, family and community behaviour. Individual, family and community values are powerful in influencing people’s behaviour [45] and we will seek to explore this more during our research.

Fear of stigmatization and discrimination may prevent people from accessing testing or getting involved in education, preventive measures and treatments services. This makes them vulnerable to HIV/AIDS infection. The self stigma and hostility in people living with HIV/AIDS inhibits them from disclosing their HIV status, seeking medical assistance or advice and so they remain in the shadows, passing the infection to others. Perhaps befriending support intervention (education) programmes (persuading: attitude and value change) should be developed, culturally appropriate to overcome the stigmatization and discriminations toward ARV treatment and adhering to medication either from health institutions or the community.

Different cultural practices (whole day fasting) may hinder female patients from adhering to ARVs because we cannot change or skip an hour of ARV dose and ARVs need to be taken after food, otherwise there is a high chance of non-adherence.

Individual (patients’) cultural beliefs or practices cannot be disregarded in order to provide information and education about ARV treatment. We must modify the ARV treatment plan to “fit” within the patient’s cultural beliefs and practices, even if we have to institute treatment that we believe is less then optimal, for instance, Direct Observed Short Course Therapy (DOTS) and community based ARV treatment. DOTS has a good track record for tuberculosis control in Nepal and if the same model can be followed for the delivery of ARV treatment services this may help adherence to ARV treatment [47] .

Disclosure by family and friends about HIV/AIDS and treatment status may build a positive attitude and consequently increase adherence. Non-disclosure of HIV status and ARVs medication may limit the uptake and adherence to treatment [48] . Thus, family and friends should encourage each other to disclose their HIV status so that they can support the patient in adhering to the treatment plan where necessary.

A comprehensive cultural approach to development requires that policymakers design and implement policies that maximise the positive aspect of culture while avoiding the negative. Thus, the role of culture works against or improves the success of the prevention and treatment interventions needed to be understood to reduce the spread of HIV at each level. That may influence the patient’s proper use of prescribed medications positively or negatively towards adherence to the regimen. For instance, optimum adherence (95% and more) to ARVs reduces morbidity and improve quality of life. [49]

Adherence to ARVs is a multifactorial behaviour and it requires a multifactorial response to achieve optimum levels (greater than 95%) because people hold diverse perceptions of health and illness, which influences attitude and behaviours. Therefore, strategies to encourage adherence must not only address interpsychic factors such as knowledge of regimen, beliefs in advantages of treatment and attitudes toward medication behaviour but we also need to see the interpersonal relationship between health providers and clients, family and peers support (community ARVs). Healthcare providers who are directly working with patients often need to educate on the value of adherence. Thus, a holistic approach needs to be tailored to promote ARV adherence. Otherwise, Nepalese cultural derivation will be influenced and nonadherence to ARVs will be more likely.

Conclusion

Culture can play a vital role in establishing the practices, values and attitudes of the public towards people living with HIV, which creates stigma and discrimination. This factor may in turn limit the behavioural choices that resulted in a barrier to go for test, begin treatment and then adhere to the medication. It affects people’s lives, whether that might be to enrich or constrain them. Thus, to reduce stigma and discrimination significantly, single level and single group approaches are not enough. It could be a patient-centred approach at the grass root level. It is quite clear that there is no magic bullet that will help all ARV patients adhere to prescribed regimens. Optimum adherence could be achieved by valuing patients’ perspectives and acknowledging the impact of individual’s beliefs on their response to treatment. We have also identified the need to address the cultural constraints which may limit the use of services offered.

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Nepal

Orientation

Identification. Nepal is named for the Kathmandu Valley, where the nation's founder established a capital in the late eighteenth century. Nepali culture represents a fusion of Indo-Aryan and Tibeto-Mongolian influences, the result of a long history of migration, conquest, and trade.

Location and Geography. Nepal is a roughly rectangular country with an area of 147,181 square miles (381,200 square kilometers). To the south, west, and east it is bordered by Indian states; to the north lies Tibet. Nepal is home to the Himalayan Mountains, including Mount Everest. From the summit of Everest, the topography plunges to just above sea level at the Gangetic Plain on the southern border. This drop divides the country into three horizontal zones: the high mountains, the lush central hills, and the flat, arid Terai region in the south. Fast-moving, snow-fed rivers cut through the hills and mountains from north to south, carving deep valleys and steep ridges. The rugged topography has created numerous ecological niches to which different ethnic groups have adapted. Although trade has brought distinct ethnic groups into contact, the geography has created diversity in language and subsistence practices. The result is a country with over thirty-six ethnic groups and over fifty languages.

Demography. The population in 1997 was just over 22.6 million. Although infant mortality rates are extremely high, fertility rates are higher. High birth rates in rural areas have led to land shortages, forcing immigration to the Terai, where farmland is more plentiful, and to urban areas, where jobs are available. Migration into cities has led to over-crowding and pollution. The Kathmandu Valley has a population of approximately 700,000.

Linguistic Affiliation. After conquering much of the territory that constitutes modern Nepal, King Prithvi Narayan Shah (1743–1775) established Gorkhali (Nepali) as the national language. Nepali is an Indo-European language derived from Sanskrit with which it shares and most residents speak at least some Nepali, which is the medium of government, education, and most radio and television broadcasts. For many people Nepali is secondary to the language of their ethnic group or region. This situation puts certain groups at a disadvantage in terms of education and civil service positions. Since the institution of a multiparty democracy in 1990, linguistic issues have emerged as hotly debated topics.

Symbolism. The culture has many symbols from Hindu and Buddhist sources. Auspicious signs, including the ancient Hindu swastika and Shiva's trident, decorate buses, trucks, and walls. Other significant symbols are the emblems (tree, plow, sun) used to designate political parties.

Prominent among symbols for the nation as a whole are the national flower and bird, the rhododendron and danfe; the flag; the plumed crown worn by the kings; and the crossed kukhris (curved knives) of the Gurkhas, mercenary regiments that have fought for the British Army in a number of wars. Images of the current monarch and the royal family are displayed in many homes and places of business. In nationalistic rhetoric the metaphor of a garden with many different kinds of flowers is used to symbolize national unity amid cultural diversity.

History and Ethnic Relations

Emergence of the Nation. Mongolian tribes from the east called Kiratis brought Buddhism in the seventh

Nepal

or eighth century B.C.E. Hinduism flourished in the third and fourth centuries C.E. under the Licchavis, an Indo-Aryan people from northern India, and after the migration of Hindus from India during the Mughal period. The Hindu Malla dynasties reigned in the Kathmandu Valley between the thirteenth and fifteenth centuries, encouraging tolerance toward Buddhism and an orthodox, caste-oriented form of Hinduism. Since unification in the late eighteenth century and through the hundred-year period of Rana rule, the culture of hill Hindus, Parbatiya, has been dominant.

The birth of the nation is dated to Prithvi Narayan Shah's conquest of the Kathmandu Valley kingdoms in 1768. The expansionist reigns of Shah and his successors carved out a territory twice the size of modern Nepal. However, territorial clashes with the Chinese in the late eighteenth century and the British in the early nineteenth century pushed the borders back to their current configuration.

National Identity. To unify a geographically and culturally divided land, Shah perpetuated the culture and language of high-caste Hindus and instituted a social hierarchy in which non-Hindus as well as Hindus were ranked according to caste-based principles. Caste laws were further articulated in the National Code of 1854.

By privileging the language and culture of high-caste Hindus, the state has marginalized non-Hindu and low-caste groups. Resentment in recent years has led to the organization of ethnopolitical parties, agitation for minority rights, and talk about the formation of a separate state for Mongolian ethnic groups.

Despite ethnic unrest, Nepalis have a strong sense of national identity and pride. Sacred Hindu and Buddhist sites and the spectacular mountains draw tourists and pilgrims and give citizens a sense of importance in the world. Other natural resources, such as rivers and flora and fauna are a source of national pride.

Ethnic Relations. The population consists of numerous racial, cultural, and linguistic groups that often are divided into three broad categories: Indo-Nepalese, Tibeto-Nepalese, and indigenous Nepalese. The Indo-Nepalese migrated from India over several

The village of Siklis, in the Himalayas. Village houses are usually clustered in river valleys or along ridge tops.

centuries; they practice Hinduism, have Caucasian features, and speak Indo-Aryan languages. They have settled primarily in the lower hills and river valleys and the Terai. The Tibeto-Nepalese have distinctively Mongolian features and speak Tibeto-Burmese languages; these groups occupy the higher hills and mountainous areas. Different groups within this category practice Buddhism, animism, or Hinduism. There are scattered tribes of indigenous Nepalis, whose origins probably predate the arrival of Indo- and Tibeto-Nepalese peoples.

Hindu castes and Buddhist and animist ethnic groups were historically collapsed into a single caste hierarchy. At the top are high-caste Hindus. Below them are alcohol-drinking ( matwali ) castes, which include Mongolian ethnic groups. At the bottom are untouchable Hindu castes that have traditionally performed occupations considered defiling by higher castes. The Newars of the Kathmandu Valley have a caste system that has been absorbed into the national caste hierarchy.

Historically, members of the highest castes have owned the majority of land and enjoyed the greatest political and economic privileges. Members of lower castes have been excluded from political representation and economic opportunities. The untouchable castes were not permitted to own land, and their civil liberties were circumscribed by law. Caste discrimination is officially illegal but has not disappeared. In 1991, 80 percent of positions in the civil service, army, and police were occupied by members of the two highest castes.

Urbanism, Architecture, and the Use of Space

Nepal historically was one of the least urbanized countries in the world, but urbanization is accelerating, especially in the capital, and urban sprawl and pollution have become serious problems. Kathmandu and the neighboring cities of Patan and Bhaktapur are known for pagoda-style and shikhara temples, Buddhist stupas, palaces, and multistory brick houses with elaborately carved wooden door frames and screened windows. Although the largest and most famous buildings are well maintained, many smaller temples and older residential buildings are falling into disrepair.

At the height of British rule in India, the Rana rulers incorporated Western architectural styles into palaces and public buildings. Rana palaces convey a sense of grandeur and clear separation from the peasantry. The current king's palace's scale and fortress-like quality illustrate the distance between king and commoner.

Rural architecture is generally very simple, reflecting the building styles of different caste and ethnic groups, the materials available, and the climate. Rural houses generally have one or two stories and are made of mud brick with a thatched roof. Village houses tend to be clustered in river valleys or along ridge tops.

Food and Economy

Food in Daily Life. Many Nepalis do not feel that they have eaten a real meal unless it has included a sizable helping of rice. Most residents eat a large rice meal twice a day, usually at midmorning and in the early evening. Rice generally is served with dal, a lentil dish, and tarkari, a cooked vegetable. Often, the meal includes a pickle achar, made of a fruit or vegetable. In poorer and higher-altitude areas, where rice is scarce, the staple is dhiro, a thick mush made of corn or millet. In areas where wheat is plentiful, rice may be supplemented by flat bread, roti. Most families eat from individual plates while seated on the floor. Though some urbanites use Western utensils, it is more common to eat with the hands.

Villagers celebrate the end of the plowing season. Most Nepalese are subsistence farmers.

Conventions regarding eating and drinking are tied to caste. Orthodox high-caste Hindus are strictly vegetarian and do not drink alcohol. Other castes may drink alcohol and eat pork and even beef. Traditionally, caste rules also dictate who may eat with or accept food from whom. Members of the higher castes were particularly reluctant to eat food prepared by strangers. Consequently, eating out has not been a major part of the culture. However, caste rules are relaxing to suit the modern world, and the tourist economy is making restaurants a common feature of urban life.

Food Customs at Ceremonial Occasions. At weddings and other important life-cycle events, feasts are generally hosted by the families directly involved, and numerous guests are invited. At such occasions, it is customary to seat guests on woven grass mats on the ground outside one's home, often in lines separating castes and honoring people of high status. Food is served on leaf plates, which can be easily disposed of. These customs, however, like most others, vary by caste-ethnic groups, and are changing rapidly to suit modern tastes.

Basic Economy. The large majority of the people are subsistence farmers who grow rice, maize, millet, barley, wheat, and vegetables. At low altitudes, agriculture is the principal means of subsistence, while at higher altitudes agropastoralism prevails. Many households maintain chickens and goats. However, few families own more than a small number of cows, water buffalo, or yaks because the mountainous topography does not provide grazing land for large animals.

Nepal is one of the poorest countries in the world. This poverty can be attributed to scarce natural resources, a difficult terrain, landlocked geography, and a weak infrastructure but also to feudal land tenure systems, government corruption, and the ineffectiveness of development efforts. Foreign aid rarely goes to the neediest sectors of the population but is concentrate in urban areas, providing jobs for the urban middle class. The name of the national currency is rupee.

Land Tenure and Property. Historically, a handful of landlords held most agricultural land. Civil servants often were paid in land grants, governing their land on an absentee basis and collecting taxes from tenant-farming peasants. Since the 1950s, efforts have been made to protect the rights of tenants, but without the redistribution of land.

Overpopulation has exacerbated land shortages. Nearly every acre of arable land has been farmed intensively. Deforestation for wood and animal fodder has created serious erosion.

Commercial Activities. The majority of commercial activity takes place at small, family-owned shops or in the stalls of sidewalk vendors. With the exception of locally grown fruits and vegetables, many products are imported from India and, to a lesser extent, China and the West. Jute, sugar, cigarettes, beer, matches, shoes, chemicals, cement, and bricks are produced locally. Carpet and garment manufacturing has increased significantly, providing foreign exchange. Since the late 1950s, tourism has increased rapidly; trekking, mountaineering, white-water rafting, and canoeing have drawn tourists from the West and other parts of Asia. The tourism industry has sparked the commercial production of crafts and souvenirs and created a number of service positions, such as trekking guides and porters. Tourism also has fueled the black market, where drugs are sold and foreign currency is exchanged.

Major Industries. There was no industrial development until the middle of the twentieth century. Much of earliest industrial development was accomplished with the help of private entrepreneurs from India and foreign aid from the Soviet Union, China, and the West. Early development focused on the use of jute, sugar, and tea; modern industries include the manufacturing of brick, tile, and construction materials; paper making; grain processing; vegetable oil extraction; sugar refining; and the brewing of beer.

Trade. Nepal is heavily dependent on trade from India and China. The large majority of imported goods pass through India. Transportation of goods is limited by the terrain. Although roads connect many major commercial centers, in much of the country goods are transported by porters and pack animals. The few roads are difficult to maintain and subject to landslides and flooding. Railroads in the southern flatlands connect many Terai cities to commercial centers in India but do not extend into the hills. Nepal's export goods include carpets, clothing, leather goods, jute, and grain. Tourism is another primary export commodity. Imports include gold, machinery and equipment, petroleum products, and fertilizers.

Division of Labor. Historically, caste was loosely correlated with occupational specialization. Tailors, smiths, and cobblers were the lowest, untouchable castes, and priests and warriors were the two highest Hindu castes. However, the large majority of people are farmers, an occupation that is not caste-specific.

Social Stratification

Classes and Castes. Historically, caste and class status paralleled each other, with the highest castes having the most land, capital, and political influence. The lowest castes could not own property or receive an education. Although caste distinctions are no longer supported by law, caste relations have shaped present-day social stratification: Untouchables continue to be the poorest sector of society, while the upper castes tend to be wealthy and politically dominant. While land is still the principal measure of wealth, some castes that specialize in trade and commerce have fared better under modern capitalism than have landowning castes. Changes in the economic and political system have opened some opportunities for members of historically disadvantaged castes.

Symbols of Social Stratification. Caste and ethnic groups are often identifiable by both physical traits and styles of dress and ornamentation. These symbols of ethnic identity along with distinctive forms of music, dance, and cuisine, continue to be important. The culture of caste Hindus is the national

Herding cattle down a dirt road. Grazing land is limited by the mountainous topography.

"prestige culture." In a process of "Sanskritization," members of diverse groups have acquired the customs, tastes, and habits of the ruling elite. Westernization is vying with Sanskritization as a cultural influence, and the ability to speak English is a mark of prestige and an asset in the job market. In cities, most men and an increasing number of women wear Western clothes. In the past, status was vested in the ownership of land and livestock; modern status symbols include motorcycles, cars, fashionable clothing, televisions, and computers.

Political Life

Government. The Shah dynasty has ruled the country since its unification, except during the Rana period from the mid-nineteenth to the mid-twentieth century. During the Rana administration, the Shah monarchs were stripped of power and the country was ruled by a series of prime ministers from the Rana noble family. In 1950, the Shah kings were restored to the throne and a constitutional monarchy was established that eventually took the form of the panchayat system. Under this system, political parties were illegal and the country was governed by local and national assemblies controlled by the palace. In 1990, the Movement for the Restoration of Democracy (People's Movement) initiated a series of popular demonstrations for democratic reforms, eventually forcing the king to abolish the panchayat system and institute a multiparty democracy.

The country is divided administratively into fourteen zones and seventy-five districts. Local and district-level administers answer to national ministries that are guided by policies set by a bicameral legislature made up of a House of Representatives and a National Council. The majority party in the House of Representatives appoints the prime minister. The executive branch consists of the king and the Council of Ministers.

Leadership and Political Officials. The government is plagued by corruption, and officials often rely on bribes to supplement their income. It is widely believed that influence and employment in government are achieved through personal and family connections. The king is viewed with ambivalence. He and his family have been criticized for corruption and political repression, but photos of the royal family are a popular symbol of national identity and many people think of the king as the living embodiment of the nation and an avatar of the god Vishnu.

Social Problems and Control. International attention has focused on the plight of girls who have been lured or abducted from villages to work as prostitutes in Indian cities and child laborers in carpet factories. Prostitution has increased the spread of AIDS. Foreign boycotts of Nepali carpets have helped curb the use of child labor but have not addressed the larger social problems that force children to become family wage earners.

Military Activity. The military is small and poorly equipped. Its primary purpose is to reinforce the police in maintaining domestic stability. Some Royal Nepal Army personnel have served in United Nations peacekeeping forces. A number of Nepalis, particularly of the hill ethnic groups, have served in Gurkha regiments. To many villagers, service in the British Army represents a significant economic opportunity, and in some areas soldiers' remittances support the local economy.

Nongovernmental Organizations and Other Associations

Aid organizations are involved in health care, family planning, community development, literacy, women's rights, and economic development for low castes and tribal groups. However, many projects are initiated without an understanding of the physical and cultural environment and serve the interests of foreign companies and local elites.

Gender Roles and Statuses

Division of Labor by Gender. Only men plow, while fetching water is generally considered women's work. Women cook, care for children, wash clothes, and collect firewood and fodder. Men perform the heavier agricultural tasks and often engage in trade, portering, and other work outside the village. Both men and women perform physically demanding labor, but women tend to work longer hours, have less free time, and die younger. In urban areas, men are far more likely to work outside the home. Increasingly, educational opportunities are available to both men and women, and there are women in professional positions. Women also frequently work in family businesses as shopkeepers and seamstresses.

Children and older people are a valuable source of household labor. In rural families, young children collect firewood, mind animals, and watch younger children. Older people may serve on village councils. In urban areas and larger towns, children attend school; rural children may or may not, depending on the proximity of schools, the availability of teachers, and the work required of them at home.

The Relative Status of Women and Men. Women often describe themselves as "the lower caste" in relation to men and generally occupy a subordinate social position. However, the freedoms and opportunities available to women vary widely by ethnic group and caste. Women of the highest castes have their public mobility constrained, for their reputation is critical to family and caste honor. Women of lower castes and classes often play a larger wage-earning role, have greater mobility, and are more outspoken around men. Gender roles are slowly shifting in urban areas, where greater numbers of women are receiving an education and joining the work force.

Marriage, Family, and Kinship

Marriage. Nepal is overwhelmingly patrilineal and patrilocal. Arranged marriages are the norm in the mainstream culture. Because marriages forge important social bonds between families, when a child reaches marriageable age, the family elders are responsible for finding a suitable mate of the appropriate caste, education level, and social stratum.

For Buddhist monks, Nepal is significant as the birthplace of Lord Buddha.

The bride's family generally provides a substantial dowry to the groom's family, while the groom's family furnishes a much smaller gift of clothing, jewelry, and personal items to the bride. Both families are expected to host a feast during the wedding festivities, which generally last three days. The cost of a wedding, especially to the bride's family, is high and often puts families into debt.

Hindu castes do not generally approve of cross-cousin marriage, which is preferred among some Mongolian ethnic groups. Among some groups, a brideprice substitutes for a dowry. In others, clan exogamy is an important feature of marriages. Until recently, polygyny was legal and relatively common. Now it is illegal and found only in the older generation and in remote areas. Child marriages were considered especially auspicious, and while they continue to be practiced in rural areas, they are now prohibited by law. Love marriage is gaining in popularity in the cities, where romantic films and music inform popular sentiment and the economy offers younger people economic independence from the extended family.

Domestic Unit. Among landholding Hindu castes, a high value is placed on joint family arrangements in which the sons of a household, along with their parents, wives, and children, live together, sharing resources and expenses. Within the household, the old have authority over the young, and men over women. Typically, new daughters-in-law occupy the lowest position. Until a new bride has produced children, she is subject to the hardest work and often the harshest criticism in her husband's household. Older women, often wield a great deal of influence within the household.

The emphasis in joint families is on filial loyalty and agnatic solidarity over individualism. In urban areas, an increasing number of couples are opting for nuclear family arrangements.

Inheritance. Fathers are legally obligated to leave equal portions of land to each son. Daughters do not inherit paternal property unless they remain unmarried past age thirty-five. Although ideally sons manage their father's land together as part of a joint family, familial land tends to be divided, with holdings diminishing in every generation.

Kin Groups. Patrilineal kin groups form the nucleus of households, function as corporate units, and determine inheritance patterns. A man belongs permanently to the kinship group of his father, while a woman changes membership from her natal kin group to the kin group of her husband at the time of marriage. Because family connections are critical in providing access to political influence and economic opportunities, marriage alliances are planned carefully to expand kinship networks and strengthen social ties. Although women join the husband's household, they maintain emotional ties and contact with their families. If a woman is mistreated in her husband's household, she may escape to her father's house or receive support from her male kin. Consequently, women often prefer to marry men from the same villages.

Nepalese men in a wedding ceremony; arranged marriages are the norm in mainstream culture.

Socialization

Infant Care. Infants are carried on the mothers' back, held by a shawl tied tightly across her chest. Babies are breast-fed on demand, and sleep with their mothers until they are displaced by a new baby or are old enough to share a bed with siblings. Infants and small children often wear amulets and bracelets to protect them from supernatural forces. Parents sometimes line a baby's eyes with kohl to prevent eye infections.

Child Rearing and Education. Mothers are the primary providers of child care, but children also are cared for and socialized by older siblings, cousins, and grandparents. Often children as young as five or six mind younger children. Neighbors are entitled to cuddle, instruct, and discipline children, who are in turn expected to obey and defer to senior members of the family and community. Children address their elders by using the honorific form of Nepali, while adults speak to children using more familiar language. Because authority in households depends on seniority, the relative ages of siblings is important and children are often addressed by birth order.

Certain household rituals mark key stages in child's development, including the first taste of rice and the first haircut. When a girl reaches puberty, she goes through a period of seclusion in which she is prohibited from seeing male family members. Although she may receive special foods and is not expected to work, the experience is an acknowledgment of the pollution associated with female sexuality and reproductivity.

From an early age, children are expected to contribute labor to the household. The law entitles both girls and boys to schooling; however, if a family needs help at home or cannot spare the money for uniforms, books, and school fees, only the sons are sent to school. It is believed that education is wasted on girls, who will marry and take their wage-earning abilities to another household. Boys marry and stay at home, and their education is considered a wise investment.

Etiquette

The customary greeting is to press one's palms together in front of the chest and say namaste ("I greet the god within you"). Men in urban areas have adopted the custom of shaking hands. In the mainstream culture, physical contact between the sexes is not appropriate in public. Although men may be openly affectionate with men and women with women, even married couples do not demonstrate physical affection in public. Some ethnic groups permit more open contact between the sexes.

Hospitality is essential. Guests are always offered food and are not permitted to help with food preparation or cleaning after a meal. It is polite to eat with only the right hand; the hand used to eat food must not touch anything else until it has been thoroughly washed, for saliva is considered defiling. When drinking from a common water vessel, people do not touch the rim to their lips. It is insulting to hit someone with a shoe or sandal, point the soles of one's feet at someone, and step over a person.

Religion

Religious Beliefs. Eighty-six percent of Nepalis are Hindus, 8 percent are Buddhists, 4 percent are Muslims, and just over 1 percent are Christians. On a day-to-day level, Hindus practice their religion by "doing puja, " making offerings and prayers to particular deities. While certain days and occasions are designated as auspicious, this form of worship can be performed at any time.

Buddhism is practiced in the Theravadan form. There are two primary Buddhist traditions: the Buddhism of Tibetan refugees and high-altitude ethnic groups with cultural roots in Tibet and the Tantric form practiced by Newars.

There is a strong animistic and shamanic tradition. Belief in ghosts, spirits, and witchcraft is widespread, especially in rural areas. Spiteful witches, hungry ghosts, and angry spirits are thought to inflict illness and misfortune. Shamans mediate between the human and supernatural realms to discover the cause of illness and recommend treatment.

Religious Practitioners. Many forms of Hindu worship do not require the mediation of a priest. At key rites of passage such as weddings and funerals, Brahmin priests read Vedic scriptures and ensure the correct performance of rituals. At temples, priests care for religious icons, which are believed to contain the essence of the deities they represent. They are responsible for ensuring the purity of the temple and overseeing elaborate pujas.

Buddhist monasteries train young initiates in philosophy and meditation. Lay followers gain religious merit by making financial contributions to monasteries, where religious rites are performed on behalf of the general population. Within Buddhism there is a clerical hierarchy, with highly esteemed lamas occupying the positions of greatest influence. Monks and nuns of all ranks shave their heads, wear maroon robes, and embrace a life of celibacy and religious observance.

Rituals and Holy Places. Nepal occupies a special place in both Hindu and Buddhist traditions. According to Hindu mythology, the Himalayas are the abode of the gods, and are specifically associated with Shiva, one of the three principal Hindu deities. Pashupatinath, a large Shiva temple in Kathmandu, is among the holiest sites in Nepal and attracts Hindu pilgrims from all over South Asia. Pashupatinath is only one of thousands of temples and shrines scattered throughout Nepal, however. In the Kathmandu Valley alone, there are hundreds of such shrines, large and small, in which the major gods and goddesses of the Hindu pantheon, as well as local and minor divinities, are worshiped. Many of these shrines are constructed near rivers or at the base of pipal trees, which are themselves considered sacred. For Buddhists, Nepal is significant as the birthplace of Lord Buddha. It is also home to a number of important Buddhist monasteries and supas, including Boudha and Swayambhu, whose domeshaped architecture and painted all-seeing eyes have become symbols of the Kathamandu Valley.

Death and the Afterlife. Hindus and Buddhists believe in reincarnation. An individual's meritorious actions in life will grant him or her a higher rebirth. In both religions the immediate goal is to live virtuously in order to move progressively through higher births and higher states of consciousness. Ultimately, the goal is to attain enlightenment, stopping the cycle of rebirth.

In the Hindu tradition, the dead are cremated, preferably on the banks of a river. It is customary for a son to perform the funeral rites. Some Buddhists also cremate bodies. Others perform what are called "sky burials," in which corpses are cut up and left at sacred sites for vultures to carry away.

Medicine and Health Care

Infant mortality is high, respiratory and intestinal diseases are endemic, and malnutrition is widespread in a country where life expectancy is fifty-seven years. Contributing to this situation are poverty, poor hygiene, and lack of health care. There are hospitals only in urban areas, and they are poorly equipped and unhygienic. Rural health clinics often lack personnel, equipment, and medicines. Western biomedical practices have social prestige, but many poor people cannot afford this type of health care. Many people consult shamans and other religious practitioners. Others look to Ayurvedic medicine, in which illness is thought to be caused by imbalances in the bodily humors. Treatment involves correcting these imbalances, principally through diet. Nepalis combine Ayurvedic, shamanic, biomedical, and other systems.

Although health conditions are poor, malaria has been eradicated. Development efforts have focused on immunization, birth control, and basic medical care. However, the success of all such projects seems to correlate with the education levels of women, which are extremely low.

The Arts and Humanities

Literature. Nepal's literary tradition dates only to the nineteenth century with Bhanubhakta Acharya's adaptation of the Hindu epic, Ramayana, for a Nepali readership. The development of literature in Nepal has been hindered by heavy government control and censorship, which led Nepali authors and poets to seek publication outside of Nepal until the 1930s, when Nepal's first literary journal,

A Nepalese person carrying a wicker basket filled with fuel.

Sharada, created a more open venue for literary expression. Among Nepal's greatest writers and poets are Lakshmi Prasad Devkota, Lekhnath Paudyal, Balkrishna Sama, and Guruprasad Mainali.

Graphic Arts. Much of Nepali art is religious. Newari artisans create cast-bronze statuary of Buddhist and Hindu deities as well as intricately painted tangkas that describe Buddhist cosmology. The creation and contemplation of such art constitutes a religious act.

Performance Arts. Dramatic productions often focus on religious themes drawn from Hindu epics, although political satire and other comedic forms are also popular. There is a rich musical heritage, with a number of distinctive instruments and vocal styles, and music has become an marker of identity for the younger generation. Older people prefer folk and religious music; younger people, especially in urban areas, are attracted to romantic and experimental film music as well as fusions of Western and Asian genres.

The State of the Physical and Social Sciences

Universities are underfunded, faculties are poorly paid, and library resources are meager. Nepalis accord less respect to degrees from universities than to degrees obtained abroad and many scholars seek opportunities to study overseas or in India. Despite these limitations, some fine scholarship has emerged, particularly in the social sciences. In the post-1990 period, political reforms have permitted a more open and critical intellectual environment.

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