Languages of Sex and AIDS in Nepal: Notes on the Social Production of Commensurability

Stacy Leigh Pigg
Simon Fraser University

There is little current information available on HIV prevalence in Nepal. —UN AIDS, Nepal: Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Diseases. 1998.
AIDS does not exist apart from the practices that conceptualize it. represent it, respond to it. We know AIDS only in and through those practices.

—Douglas Crimp, i4/D5. Cultural Analysis, Cultural Activism

AIDS has been experienced in Nepal mostly as an expected epidemic. When epidemiologists in the late 1980s began warning that South Asia would soon be hit by an exponential increase in the rate of HIV infections, international donors moved to put prevention programs in place. The result in Nepal was a distinctive burst of relatively well-funded, concentrated AIDS awareness programs. The accompanying rise in publicity about AIDS far outstripped any collective, public awareness that anyone in Nepal might actually be suffering from AIDS. The publicity surrounding a few individuals with AIDS did little to challenge a pervasive sense of the remoteness of AIDS from Nepali life.1 This relative invisibility of AIDS as illness in Nepal makes the visibility of organized prevention efforts of the 1990s remarkable. Public knowledge about AIDS in Nepal in the 1990s was being created, to an extraordinary degree, out of an already formed template of accepted facts about HIV, and the public health wisdom about AIDS prevention that accompanied that information, as set out by powerful international organizations. This means that Nepali health planners and activists, together with the public at large, encounter AIDS—as an idea, and for some, a physical reality— through the mediation of an AIDS expertise that is already firmly consolidated.2 This creates a situation that differs from the experience in the 1980s in places such as Haiti or East'Africa, when scientific knowledge was evolving rapidly. In the first decade of AIDS, the effects of AIDS on bodies and lives
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was already being felt even as the earliest cpidemiological, clinical, and virological research was beginning to describe and define the phenomenon. In contrast. Nepal's experience in the second decade of the AIDS epidemic in Nepal is of a now well-established set of medical and policy frameworks being applied in an attempt to forestall a predicted (and, no doubt, likely) health disaster that has not yet hit. What happens when this internationally standardized set of facts and policy wisdom hit the ground, so to speak, in Nepal? What are the processes through which Nepalis come to recognize the existence of something called AIDS, learn what it is. form ideas about who should be concerned, and judge whether or not they should care? In this article I attend to the communicative difficulties that arise as a template of internationally established knowledge acquires a local life through the efforts of Nepali AIDS workers to bend it, mold it, or force it to accommodate the contours of the Nepali social ground. These efforts are a site where transnational circulations of western scientific knowledge and its allied areas of applied management expertise (such as public health) enter into and intersect with other knowledges and mass-mediated public consciousness. The traffic in facts, explanations, and technologies of science is an important, but underexamined, site where the distinctions between local and global forms of consciousness and identity is produced. I thus want to consider how the knowledge generated by science travels to the so-called underdeveloped peripheries in order to connect its movements to questions about emergent global modernities and the social positions and material possibilities these create (on the conceptualization of global circulations, see Tsing 2000).4 These processes are implicit in the task of teaching people in Nepal about AIDS. The issue of translation looms large in the everyday work of fostering what is called "AIDS awareness." for Nepali AIDS workers routinely move between ideas formulated in English and their expression in Nepali. The linguistic labor of Nepali AIDS workers is. I argue here, an important practice that creates routes of movement and nodes of connection through which science travels. In the ethnographic sections that follow. I focus more closely on Nepali AIDS workers1 views of the expressive capabilities of Knglish and Nepali. I take seriously their sense that AIDS education requires switching between English and Nepali, and I look at the different valence the use of Knglish has in the explanation of AIDS and in the discussion of sex. At issue is the way specific choices of language organi/e the movement of knowledge, especially knowledge that gains international acceptance as factual as a result of scientific research. What comes to count as a translation of a concept, and at \shat points docs translation fail? AIDS education in Nepal thus provides a case study that sharpens our locus on what I call the soefal production of conimensurabilitv. This concept is useful for helping us think about the actual presence o\ technoscience. including medicine, in out-of-the-way parts of the world, for it takes us beyond discussions of systems of knowledge that tend to come to rest in an overly static, binary and implicitly hierarchical vocabulary of difference (Abu-Lughod

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1991).^ Knowledge is more dynamic than that: If we merel\ envision different knowledge systems bumping into each other, or supplanting one another, we risk oversimplifying the already syncretic, hybrid, polyglot conditions with which most people contend. Much work in science studies has focused on the stabilization of facts through social exchanges that produce consensus on how to read the evidence and see the world. From this work we have learned about the social milieu in which controversies are resolved and scientific knowledge is produced, and, moving outside the laboratory, about the meaning this knowledge acquires in the public imagination and the cultural metaphors that in turn seem to shape how scientists envision their objects of investigation. One approach in medical anthropology traces the ways knowledge about the body is formulated, represented, legitimated, and used in a given context (Lindenbaum and Lock 1993; Lock and Kaufert 1998; Lock and Scheper-Hughes 1990; Rhodes 1990; Young 1982). A l t c n t i ° n t o t n e production of knowledge as it occurs in specific contexts opens up for examination the relation among heterogeneous, overlapping, and perhaps contradictory means of knowing and manipulating the body in health and illness. The knowledge production approach can be enhanced to take translocal and global processes into account by a greater attention to how certain practices bring forth new potentialities for connection and stabilize them institutionally. It is necessary to take the investigation of knowledge production in science beyond the center comprised of North American and European laboratories, clinical expertise, public health policy and activism. Attention to the social production of commensurability raises the following questions: What are the practices through which actors forge, provisionally or lastingly, common measures, standards, and frames?'1 How are perceived differences bridged or mediated? What are the consequences of the routini/.ation of certain conceptual paths of connection? What links the social production of facts in one site to the acceptance of them in another? And what, in the context of an epidemic, might the consequences of these patterns of linkage be? These questions point toward analysis of the ways science moves both outside the laboratory and outside the West. The concept of language ideologies—that is. the beliefs and assumptions people hold about the nature of their own and others' languages—is useful for understanding what occurs in the translation and communication of knowledge about AIDS.7 International health programs exhibit a language ideolog) in the common sense assumptions of their approach to communication. Reflecting an underlying notion that languages are sets of labels (Good 1994). international health programming rests on the idea that truth is independent of language and that knowledge is merely contained in the packages that are words. The task in international health education, then, is to move bits of information from one social location to another by finding the right words in another language in which to package it. AIDS awareness education consists of the communication of basic biomedical understandings of HIV transmission and AIDS, on the one hand, and a sex education component, on the other. Nepali AIDS workers charged

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with imparting this education say their job is "very difficult." "We can't talk about SXA in our society,"! n} they say, and they see this as both a source of opposition to AIDS programs in general as well as a barrier to the communication of the AIDS "message." (Here and throughout this article I use underlining to indicate English words used within Nepali utterances. To show the primary language of the utterances I have quoted. I use {n} to indicate Nepali and {e} to indicate English.) AIDS workers comment much less on the fact that, in practice, they also find it quite hard to explain AIDS in Nepali. Perhaps even harder, for while sexual organs, acts, and feelings are within the realm of people's experience, AIDS is (for a Nepali audience) only a concept involving an imprecise set of possible afflictions coming after an indeterminate period in which invisible organisms do something to microscopic particles in a part of your body (the immune system) that you don't even know you have. Nepali AIDS workers' sense of the "difficulties" in AIDS education, and the language ideology this reflects, greatly influences the practices through which they implement strategies of AIDS education that are encouraged by the international experts who fund their work. This has real effects with implications lor equitable access to knowledge. International health wisdom sees issues around communication about sex as a problem of culture, while issues around communication about AIDS are seen as a problem of knowledge. Beliefs in international development about knowledge and translation are inflected by the content of the knowledge to be transmitted. In AIDS education efforts, the reasoning goes something like the following. If it is a bit tricky to explain AIDS in Nepali, it is because the Nepali population, as a whole, has not yet been sufficiently saturated with correct biomedical information about the body. Raising awareness of AIDS is a matter of replacing misconceptions with the facts. Once the Nepali public knows "the facts." this line of reasoning assumes, they will naturally and easily think about them in their mother tongue. The problem of translation is a problem of conceptual disparities, to be solved by information. It it is hard to talk about sex in Nepali, on the other hand, it is because the "culture" prevents Nepalis from talking about it with the transparency and frankness that is required. It is embarrassment that gets in the way of communication about sex. not conceptual problems, because after all (this line of reasoning presumes) sex is a universal human preoccupation. Sexuality is assumed to exist, independent of culture, as a bedrock on which culture imposes rules and restrictions (as Vance 19^1 notes). Of course (it is assumed). Nepalis are already thinking about sex. in Nepali, and the only task is to overcome the culturally imposed inhibitions on speech. So goes the standard thinking in mainstream AIDS prevention discourse. The facts ol AIDS are merely to be made evident and explained. A closer look at language choices in actual communication about AIDS and .sex shows that internationally established truths -about AIDS and about sex—do not convert into local languages as readily as the referential concept of language presumes. My ethnographic project on the production of public knowledge about AIDS in Nepal quickly became an effort to trace on the

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ground just what is involved in actually making evident and explaining: to understand when, how, and why communication is and is not a problem. For seven months in 1997, I followed the work of Kathmandu-based nongovernmental organizations (NGOs) involved in AIDS prevention activities.*" 1 talked to many NGO leaders and outreach workers about their activities, their ideas about what their fellow citizens need to know and how that information should be conveyed to them, and their personal feelings about their work. I participated in workshops held for targeted audiences as diverse as film actresses, college students, and teenage women who had returned to Nepal from sex work in India, and I sat in on (and contributed to) meetings in which educational materials were designed and discussed. AIDS workers (an umbrella term I use to refer broadly to outreach workers, NGO leaders, and officials with a role in AIDS-related policy) were preoccupied with issues of communication, in part because several major international donors had been, up until that time, stressing what are called IEC (Information, Education, and Communication) strategies. Teaching people about AIDS—creating "awareness"—through mass media campaigns, educational materials, and sex education remains the focus of most NGO efforts, and this is why I focus here on communication even though the circulation of international expert knowledge clearly has many nondiscursivc dimensions. Before turning to the analysis of Nepali AIDS workers* efforts to make AIDS known, I address, in the next section, some of the politics of theory in the international context. It is a tricky business to use theories of language to look at AIDS. Debates emanating from science studies rub against debates about the politics of strategies of AIDS prevention, and both point up some unresolved tensions between anthropology's relativist and humanitarian commitments. I sketch these issues as a necessary precursor to the ethnographic discussion of language in AIDS and sex education in order to open up larger questions about the public understanding of science on the peripheries. In the conclusion of this article I offer a vision, albeit preliminary, that might bring to science studies a closer consideration of the development practices through which so much of science extends itself into the out-of-the-way places that have so persistently figured as the ground against which the progress of modern scientific knowledge is measured. One World, One Hope? As the international conference on AIDS opened yesterday under the slogan "One world, one hope." it became clear that there are two worlds when it conies to fighting the deadly disease. In one. the rich can bn\ pills and optimism. In the other, the poor can only hope for prevention to save them from despair.9
—The (ilohe and Mail. July X. 1996

So began the front page article on the XI International Conference on AIDS in Vancouver in Canada's leading daily newspaper. This major scientific conference was the actual starting point of m> ethnographic research and the question

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posed by its theme neatly encapsulates the larger context in which AIDS prevention efforts in Nepal are embedded. Much of the "hope" for AIDS around the world is pinned on science. This is as true of the mild hope resting in education as a step toward prevention as it is of the more energetic hope vested in overcoming the stark inequality in the distribution of state-of-the-art drugs. Both these hopes point to a further question: How is "one world" of AIDS knowledge, political action, and treatment created? Communication is one means (though certainly not the only means) by which a stable, internationally unified world of AIDS knowledge/intervention comes into being. International health activities based on "AIDS" (as it is known and described by science) work at the cusps where this consolidation cannot be taken for granted and must, instead, be made to happen. To approach world-unifying truths, it is necessary to begin by situating knowledge, and the processes by which that knowledge is achieved and made to matter, in the world, in specific social and historical contexts.10 This analytical move is sometimes seen as discrediting knowledge gained through scientific research or dismissing the utility of its insights into nature. But Latour (1999) has pointed out that work in science studies addresses the social not in order to debase science (though it does dethrone certain kinds of legitimating claims), but in order to support what he calls a more realistic realism." Far from undermining our grip on reality, the aim is to see more clearly the dynamics and organization of interactions between people and the world. Science does not simply find and uncover the secrets of nature. It reconfigures our relationship to nature through an active engagement that is itself productive and not simply descriptive (Haraway 1997; Latour 1987, 1999). Scientific standards vary through time and across areas of inquiry; controversies among scientists themselves produce differing accounts of the objects they seek to explain; and stability and reliability of any account is produced through scientific work. Rather than thinking about this in terms of the abstract relativism of knowledge, according to Latour (1999:174-215), we should conceptualize this as a process through which intimate relations between nonhumans and humans become folded into the everyday fabric of collective life. This approach, far from adopting a radical skepticism toward science, takes .scientifically-generated knowledge very seriously by asking about how complex objects like pi. oncogenes. neutrinos, gravity waves. . . airplanes [and I would add HIV. AIDS, and the AIDS epidemic! emerge, stabilize, and then produce a wide variety of real effects in our technosociocultural world. [Fujimura 1998:357. emphasis addedl Looking at Nepal, one could'argue that in an important sense, communication about AIDS "is" AIDS. A complex set of relations and processes (among proteins, cells, and so on) can only become "AIDS" for human actors in Nepal because of the relations that link the thinking of people who conduct research on HIV/AIDS in clinics and laboratories to ordinary Nepalis.

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But does not HIV exist whether or not some Nepalis know about it? Latour (1999:145-173) has argued that a scientific fact never emerges solely out of the singular event of discovery, but requires continued institutional upkeep, action, and work to remain true. Pasteur's microbes exist not because Pasteur once convincingly said so, but because we "live inside the Pasteunan network, every time [we] eat pasteun/ed yogurt, drink pasteurized milk, or swallow antibiotics" (Latour 1999:168). Latour further argues that this is not simply a matter of changing frameworks of understanding on our part; when people begin to think and behave differently in relation to attributes and processes they perceive in the world, this is also an event in the history of the nonhuman actors involved. New scientific findings replace old ones and the world changes as a result, not because there is a substratum of independent, ahistorical nonhuman substances behind all that happens but because the actual wa\s nonhuman actors are brought into human history makes things happen in the way they do. This is not an either/or proposition (either microbes have always existed or they have never existed until they were imagined as such by people); it is an assertion that takes seriously the historicity of the interaction between the forces, properties, and attributes of nonhuman actors and people engaged in specific practices, and the capacity ol these interactions to affect both the world and human understandings. One of Latour's main theoretical concerns has been to replace the all-or-nothing terms ol truth and reality in which questions of the relation between representations and things are so often posed with a vision of gradients, continuums, linkages, that are established and maintained via locatable material practices. 12 The "reality" of HIV can be seen in this light. HIV "exists" whether or not some Nepalis know about it because there are other people in the world, organized in powerful institutions, for whom knowledge about HIV and the AIDS pandemic is the basis for a series of actions, sonic of which have apparent results for peoples health, as well as lor the ability of the thing we call HIV to reproduce and survive. The issue of communication about AIDS in Nepal raises a question about how we might understand the place of Nepal, and other places similarly on the periphery, as part of "our technosociocultural world." Nepalis are implicated in AIDS science not simply as potential, but largely passive, beneficiaries (Clarke and Montini 1993) but also as teachers, translators, outreach workers, and peer educators whose actions help bring HIV/AIDS into existence in new contexts. Some AIDS activists and cultural critics in the industrialized West have worked with savvy theories of language, power, and the social construction of science to continually question the stability and effects of knowledge about AIDS as it is produced by researchers and clinicians and then taken up b\ politicians, policy makers, service organizations, and people in various life situations. No other health condition has had the process of its discover), investigation, and management so thoroughly scrutinized even as the science was very much in the making (Epstein 1996; Patton 1990; Ireichler 1999). Activist-experts have raised questions not only about access to the latest knowledge and treatments, but also about the processes through which the priorities and

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procedures of scientific research on AIDS have been set and treatment protocols established. Most of the intervention-oriented thinking about AIDS programs in the Third World has been largely simplistic in comparison. Fixated as most international AIDS programs are on identifying the constraining "beliefs" of the cultural other," little thought is given to the politics of know ledge about AIDS in these other locations. Paradigms lor intervention are hotly debated, to be sure, but there is little reflection on the ways the implementation of a given paradigm involves communication practices that themselves establish the contextual "reality" of AIDS.13 The emphasis is on imparting information in order to reduce risk. Here it is important to understand a debate within international AIDS circles. AIDS research and program design has been guided overwhelming by a behavior change model that emphasizes cognitive processes. Proponents of a social vulnerability paradigm <Farmer et al. 1996; Mann and Tarantola 1996; Parker 1996) argue that attention should be directed at the social and political context that creates conditions of vulnerability. Instead of focusing on deficiencies in people's "awareness," or states of mind, as the reason why people fail to protect themselves from HIV infection, we should be attending to how life conditions rooted in economic inequality become manifest in conditions of health, dynamics of relationships, and sexuality. Whereas the behavior change model medicalizes both sexuality and AIDS, the social vulnerabiliu model politicizes them. It is important that an analysis of AIDS prevention education avoid furthering what Farmer et al. (1996) call "immodest claims of causality" and "exaggeration" of the effects of education on risk reduction. One way to begin is by noting that reactions to AIDS are very much a part of what AIDS is. and that we never encounter "AIDS" in the abstract, apart from some matrix of knowledge about it. Without falling into simplistic truisms about AIDS education, we must recognize that information and modes of communicating, more broadly, are of real social value to Nepalis. Without it. how is there to be a political debate—let alone political mobilization—within Nepal about responses to AIDS? It could be argued that a preoccupation with communication on the part of Nepali AIDS workers—as manifest in the time and energy devoted to wrangling over word choice, the phrasing of messages, the illustrations on posters, and the known or imagined reception of their AIDS education efforts—served as a comfortable diversion from a more politically incisive engagement with the social inequalities linked both to HIV transmission itself and the choice of intervention strategies. I think this is the case, but it is not an adequate account of what is going on. It is necessary to pay attention to the series of .small actions and apparently reasonable choices that accumulate into a political effect. There is something to be learned from lollowing the communication practices that count as AIDS education in Nepal and from considering the concerns of the workers who produce and disseminate AIDS messages to other Nepalis. There are important questions here about the exclusions and possibilities created

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by modes of communicating information about AIDS. Who is able to understand, or listen to, what kinds of explanations? This is a question about the local distribution of information—a particular stabilized understanding of the complex objects HIV and AIDS—that is valorized international!) for a variety of reasons.14 It is necessary to tie questions about the formation and stabilization of scientific know ledge more firmly to questions about the circulation of this knowledge and to consider local distributions of knowledge in relation to international distributions of knowledge. It has been hard for anthropologists to take up this challenge, perhaps because our relativist and humanist commitments seem to collide on this point. On the one hand, many voices are asking whether the knowledge produced by science is as pure, value-free, and universal as it presents itself to be.!S Such questions are born of relativist considerations about systems that make sense in their own terms and of multiple measures of truth, value, and legitimacy that people might apply. This line of thinking encourages us to think about systems of knowledge as incommensurable. On the other hand, most responsible critics, however much they question over-generalized claims to objectivity and universality in science, still insist that there are benefits of science and medicine to which everyone in the world should have access (Harding 1994:322; Lock and Scheper-Hughes 1990:49). These are humanist claims that give the efforts of science, technology, and medicine a place in struggles for improved conditions of living in the name of social justice (Farmer 1999 makes this case with great passion). Such claims generate a new set of pressing questions about which benefits of science and medicine would serve this cause, who decides, and how access to these benefits would be organized. HIV/AIDS is one of those problems of human life for which the claim that everyone ought to have the benefit of the best information, prevention strategies, and treatments has been especially compelling, albeit poorly realized in practice. Moreover, what is "best" in addressing HIV/AIDS remains a subject of intense debate in most areas of AIDS-related research and activism. M> attention to language is intended as an exploration of the question of access as it is made possible at the level of consciousness, and this, admittedly, is but one dimension of the problem. This is the question of how information gets to people, how people come to participate in the gold standard that is the germ thcorv of disease, how (hey might begin to think about actions in the name of disease prevention. "They Don't Even Know What HIV Is" It is hard for Nepali AIDS prevention workers to imagine a form of useful AIDS education that is not firmly tethered to the (simplified) biomedical idea that there is a distinct condition known as AIDS and that it is caused by infection with HIV. Nepali AIDS workers tend to measure what they call "ignorance" about AIDS in terms of people "not even knowing about HIV." Imparting this information in Nepali is a linguistic chore.

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Talal Asad has insisted that "the process of 'cultural translation" is inevitably enmeshed in conditions of power" (1986:163). His insight can be extended to apply to the mundane, practical communication activities of international health. Asad, following Walter Benjamin, reminds us that translation is transformation, and that the hybrid forms it generates are produced under historical conditions of inequality: because the languages of Third World societies . . . are "weaker" in relation to Western languages (and today, especially to English), they are more likely to submit to forcible transformation in the translation process than the other way around . . . Western languages produce and deploy desired knowledge more readily than Third World languages do. [ 1986:157-158] The convolutions required to explain the terms HIV and AIDS in Nepali in various educational sessions was for me a vivid illustration of Asad's point. Explanation of the acronym AIDS and the abbreviation HIV is the standard starting point for most AIDS awareness education. The word "AIDS." being easily pronounceable in Nepali, quickly entered colloquial language and is rendered in print in the phonetic devanagri script as "^r. To explain the acronym thus requires converting this Nepalicized AIDS back into AIDS, roman alphabet. English acronym (see Figure 1). Then the English word lor which each letter stands is provided. The next step is to translate these especially technical English words into Nepali. This can quickly devolve into a wordy endeavor requiring more and more explanation, given that the dictionary-defined technical words in Nepali for "acquired." "immune system." "syndrome." and even "\ irus" are not necessarily easily intelligible to even rather well-educated Nepalis. who sometimes need the English definition to understand the Nepali equivalent. No wonder "explain the full form of AIDS" was a stock question in the ever popular quiz contests for school children. Why is it so hard? Our tendency, of course, is to sec it as a problem rooted in Nepali language and culture: It is because the Nepali language lacks a word for immune system, we say. or because many Nepalis do not grasp the germ theory of disease that it is hard to explain what HIV and AIDS are. We could, however, look through the other end of the telescope, so to speak. It is just as true that due to some historical quirks in the way clinicians, epidemiologists, and basic scientists began to investigate what we now call AIDS, it has conic to pass that everyone else in the world, down to a perplexed Nepali villager, is stuck with this cumbersome terminology. All disease names are artifacts that bear the traces of the history of attempts to know them, but in the case of AIDS this history is both fresh and remarkably open to scrutiny. We have the term AIDS, after several other labels were discarded, because epidemiologists at the Centers for Disease Control "'had to define what constituted a ease" in order to investigate this "fatal disorder of unknown origin and indefinite proportions" (Oppenheimer 1988:272. 270). It is because it took three long years to discover a retrovirus that appeared to be the causal link, because a law suit over the patent rights to the antibody test became an international diplomatic incident, and

L A N C l A ( . l S O h S I X A M ) A l l S IN N K P A I

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jft ?
HIV
try. * T ^tTf^r-j A I D S
ir

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A I D S

Acquired Immune Deficiency Syndrome
F ignre 1
<]*]?* i

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Phe acronym ' MDs" unpacked and translated into Nepali. Detail of poster produced bv \K< VNi p. il with support from \mF \R ca.

because the dispute between Robert Ciallo and I uc Montagnicr over its discov er> and naming had to be adjudicated bj the International Committee on the axonom) of \ iruses that we have the term HI\ (Epstein 1996:77 Oppenheimer 1988). The distinction between infection with HIV and the condition ol fullblown AIDS is emphasized because of institutional needs to standardize clinical ease definitions and orsani/e insurance, disabihu leave and other entitlements.

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and for activists an emphasis on this distinction was a semantic way to focus attention on the needs and quality of life of "people living with HIV" and to counter the "death sentence" imagery AIDS quickly acquired."1 l.very time a Nepali AIDS worker becomes embroiled in contorted explanations of "what HIV and AIDS stand for." he is implicated without realizing it in the recent history of "science in the making" (as Latour 1987 puts it) in distant centers of sophisticated scientific research, as well as in the distant contexts in which this distinction matters. Asad rightly saw in acts of translation a question of power relations, as manifested in a global hierarchy of value attributed to different knowledges. As we will see, the desirability of knowledge about AIDS is very much at issue in AIDS prevention communication. What counts as knowledge about AIDS? Who has that knowledge? Who wants it, who needs it, and why?

From Development Donors to Public Culture: The Formation of an AIDS Discourse
Although HIV is a very cosmopolitan microbe.AIDSdiscour.se . . . has always been provincial.
—Paul Farmer, AIDS and Aci-u.sation

Nowadays when your marriage is being arranged your family should demand an HIV test along with the horoscope! —quip among young middle-class women in Kathmandu In 1992, the number of HIV infections ever identified in Nepal was 1 I4.17 That same year, the American Foundation for AIDS Research (AmFAR) received over 80 applications from Nepali NGOs wishing to be funded to carry out AIDS prevention activities. Interest in AIDS intervention work has been donor-driven, part of a general shift of attention toward AIDS in Asia. Between 1990 and 1993, The World Bank, the United Nations Development Program (UNDP), the European Economic Union (KFU). the United States Agency for International Development (USAID), and several other smaller donors specifically commissioned preliminary studies or started active AIDS programs in Nepal.1H By one estimate, international AIDS-related funding increased by 99 percent between 1992 and 1993 (Mann and Tarantola 1996:530). A 1996 inventory showed that 21 separate government offices. 12 multi- and bilateral organizations. 2S International NGOs (INGO), and 45 Nepali NGOs involved in AIDS-related activities. Two initiatives were highly publicized. AIDSCAP (AIDS Control and Prevention Project). USAIDs worldwide "AIDS strategy." set up a Nepal program in 1993. the same year AmFAR decided to focus its small international program in a single country as a sort of "laboratory" of AIDS prevention (Haniium 1997; Pigg 2001). Both AIDSCAP and AmFAR programs were to be carried out by local NGOs (in the case of AIDSCAP, each doing a different job in the overall program; in the case of AmFAR. each working independently with its targeted community with initial

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technical assistance and support from Save the Children Fund-U.S.). These programs, initially budgeted at approximately 2 million and 3 million dollars, respectively, were launched precisely at the time that the number of NGOs in Nepal burgeoned (by some reports, tenfold) after the restoration of multiparty democracy in 1991. AIDS intervention work took form in Nepal at a particular moment in its history of national development bureaucracy. Critics in Nepal have suggested that all AIDS work is merely a way of chasing the donor dollar in an era when development-oriented NGOs are (they say) an entrepreneurial form. This view, whatever its kernel of truth, overlooks the reasons to worry about an HIV epidemic in Nepal, even in the absence of reliable epidemiological data.|y HIV/AIDS has in many places become a disease of poverty, following, in Paul Farmer's words "steep grades of inequality" (Farmer et al. 1996; for Nepal. Seddon 1997).20 There is a dearth of empirical data on the pattern of the epidemic in Nepal, and most expert representations of patterns of HIV transmission (including my own, here) must rely on extrapolations from epidemiological patterns discerned from research elsewhere. International donor concerns based on international, not Nepal-specific, knowledge of the epidemic was the catalyst that formed a vision of a potential AIDS problem in Nepal. International knowledge gave Nepal both a formulation of the problem and a path toward solutions. The push to launch AIDS prevention programs in Nepal has driven, and indeed legitimated, new forms of institutional attention to sex. "Sex 1 appears in the institutional worlds of health development through three main efforts: (1) a focus on the prevalence and management of sexually transmitted diseases; (2) attempts to research sexual behaviors, including the incidence of prostitution; and (3) promotion of sex education as an aspect of health education.21 That these are the priority areas reflects not only the centrality of sexual transmission in the epidemic but also certain orthodoxies of international AIDS prevention.22 Attention to AIDS therefore has come to mean, in a very practical sense, an attention to the sexual activities and sexual consciousness of Nepalis in the name of disease prevention. That is what AIDS prevention work is understood to be all about. Indeed, the idea that AIDS is "about* sex in a unique way could only be underscored for people seeing unprecedented public displays such as a made-for-TV movie in which Santosh Pant, one of the country's most famous comedic actors is depicted having sex with a prostitute (he is unable to find a condom and becomes infected with HIV). Girl-trafficking featured as a subplot in a weekly TV serial drama aired in 1997; AIDS was invariably mentioned in the frequent newspaper stories about arrests of prostitutes and raids on the new "massage parlors" that had sprung up in the tourist district and were assumed to be a cover for bqpthel-like activity. Unlike other ubiquitous features of the urban public landscape that people saw as putting sex in the public eye—blue films, soft pornography magazines, the eroticism of Hindi films, the sex scenes in TV shows and films made in the West, and posters of scantily clad white women in alluring poses—AIDS intervention had an official imprimatur

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when it made sex publie. The message was clear. Unlike the illicit pleasures of pornography. AIDS information was supposed to be good for you and good for your society. Disease prevention is loosely associated with national development, if only because disease prevention campaigns come through the deep channels carved by the movement of funds through the development infrastructure. From the perspective of workers in the development industry. AIDS programs introduced new, odd, and decidedly awkward problems by forcing sexual matters into a new idiom of official attention.23 Suddenly matters like prostitution, STDs, and patterns of sexual behavior were brought into the work place. The need to discuss sex-related topics as part of one's professional work created contradictory situations in which the lines between professionalism, prurience, and personal moral propriety often blurred. There was a widespread sense of nervousness around AIDS prevention activities. Some people reacted by pushing for direct and frank discussions of sexual matters in the name of public health, while others demurred with arguments that such approaches were unnecessary, premature, or inappropriate in Nepal. Of course, given that population control efforts have been a cornerstone of health development since the 1960s, sexuality has, in a sense, long been a development concern. But from the perspective of development workers, the AIDS intervention work sponsored by donors was different. One communications official I interviewed insisted that "Family Planning just isn't about SJLX. the way AIDS is"{n}. He went on to explain that family planning can be approached as a problem of population growth, and therefore discussed in relation to environmental degradation, the national economy, and the household budget. But AIDS, he said, "touches directly on ^eji.. AIDS, prostitution, condoms, these are all about §jix"{n}. By 1997, tensions between busmess-asusual on the family planning circuits of development and the more experimental work of AIDS prevention were evident. These two wings of health development work were being brought together under the rubric of reproductive health, in keeping with views that it is counterproductive to single AIDS out in educational efforts. Many in the family planning field felt that the new AIDS orthodoxy of condom promotion was in conflict with the family planning orthodoxies that emphasize sterilization and depo-provera. Accustomed to denying contraceptive access to the unmarried, some family planning workers outraged certain AIDS workers by refusing to give information on HIV risk and the use of condoms to unmarried young people. Where family planning was understood to deal with socially sanctioned sexual relations (making it possible to deal with sex indirectly through references to "husband and "wile and "children"), the AIDS issue draws attention to all the ways in which the ideal of premarital chastity ;md marital monogamy are violated in real life. Thus the very task of promoting AIDS awareness seemed to many people, both inside and outside development circles, to be out of synch with Nepali culture and society. In many nations, AIDS has been viewed as a foreign disease, a danger to citizens only to the extent that national borders are penetrated

LANGUAGES OF SEX AND AIDS IN NhPAL

-W

by diseased outsiders (lor the example of Japan, see Buckley 1997). AIDS carries these connotations in Nepal as well. Yet in contrast to the many governments that have blocked internationally sponsored AIDS intervention agendas, the Nepali state—while not particularly enthusiastic, and certainly not without qualms about being seen to violate public morality—has proven remarkably open to internationally sponsored AIDS intervention activities (carried out mostly by NGOs). This apparent openness is undoubtedly due to the state's weak position vis-a-vis development donors, in general. The interesting result is that in Nepal, it is not only AIDS that is marked as foreign, but the practices of AIDS intervention themselves. Ambivalence about the foreign values, priorities, and sensibilities embedded in international AIDS intervention templates is played out subtly in the actual communication and reception of knowledge about AIDS. Communicating AIDS: A Brief History of "The Message" They thought it was like doing AIDS education in the L'S. except in a different language. —wry criticism made by a former employee of the AmFAR AIDS prevention initiative in Nepal. Why would there be any problems of translation? All the programs have Nepali staff producing the material. —comment of a USA1D official on my research question. When workers involved in giving form and substance to the idea of AIDS described their work as "very difficult." they mostly meant the difficulty of talking publicly about sexual matters. But they also saw it as the difficulty of trying to make people care about something that seems irrelevant, distasteful, or ungrounded. The question of how to talk about sex and AIDS, indeed the question of what it means to talk about sex and AIDS, was not merek an abstract issue of public health for AIDS workers, for they felt the implications themselves, as individuals, in the choices their organizations made. "Go say these things to your own sister!" was not an uncommon insult hurled at male AIDS workers by the supposed beneficiaries of their information campaigns. They felt people whispered about them "unlharulai pani txastai holat" (they must be one of those [afflicted with AIDS because of their unregulated sexuality]). Nepalis are not unique, of course, in their struggles to find ways to address AIDS and sex (see. for instance, Crimp 1988b on controversies within and around North American urban gay communities; Brandt 1987; damson 1990; Pliskin 1997 on STDsi Nor do I mean to imply that Nepali society is weighted down somehow by a higher quantum of moralism. or shame, or repression, or conservatism, or anything else that is usually seen as a barrier to the smooth communication of "the facts" about AIDS. The point is not whether the situation in Nepal is unique, but rather how Nepali actors understand it as

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their situation. Within AIDS prevention circles, the difficulty of talking about sex and AIDS tends to be viewed as a problem of "our Nepali society." Workers views are thus consonant with the dominant perspective in international health practice, a perspective that consistently pits its commitment to scientific truths that can save lives against the cultural beliefs that impede people from accessing them. International health programs are dominated by behavior change models, and within these models culture is treated as "a set of beliefs, values, and individual goals that pattern behavior . . . individuals are constrained by their image of normative action as they seek to conform to the values of their society" (Yoder 1997:135). This conceptual scaffolding leads to a practice in health education campaigns whereby information is sought about "local idioms of expression in order to better communicate health messages" (Yoder 1997:138). Yoder clearly points out the isomorphism between the science/culture split and the modus operandi of international health programs: Setting up belief and knowledge as clearly contrastive has certain advantages tor health educators, since the task of health education then becomes teaching biomedical knowledge to a population unaware of its implications. This approach fits well with our own commonsense tradition, which conceives of lay knowledge as a faulty derivative of biomedical knowledge. It assumes that as knowledge improves in accuracy, healthier practices will follow. When they do not. this m.i\ be explained by citing local cultural beliefs [1997:138] Nepali AIDS workers follow this line of reasoning. 24 The earliest public information messages on AIDS in Nepal used images of death to instill fear. Donors and technical advisors (both expatriate and Nepali) quickly put a stop to that. They introduced the now established wisdom of positive AIDS communication to NGO personnel who. as a result, developed a philosophy of AIDS communication often at odds with the approach coming from the National Centre for AIDS and STD Control [NCASC]. A consortium of the AmFAR-funded AIDS NGOs began meeting in the Information. Education, and Communication Committee (IECC) to "peer review" proposed posters, jingles, and pamphlets (Frey and Pyakuryal 1995). The IECC (whose membership was later expanded to include representatives from NCASC and AIDSCAP, as well as other organizations such as United Missions to Nepal) eventually became one of the few nodes of coordination of dispersed efforts to develop AIDS education materials. Guided by a set of principles of health communication that had been laid out in a workshop led by technical advisors, the IECC established, over time, the method and approach I discuss here. By 1994. under AIDSCAP and AmFAR funding, fear-based messages were replaced with a spate of materials presenting "how HIV is transmitted fkasarl sarchaT as th c information about what AIDS is. Encapsulating the HIV-causes-AIDS message, the electron micrograph image of HIV was a favorite motif in pamphlets (see Figures 2 and 3). Anticipating possible misconceptions, these messages about HIV/AIDS typically balanced every point about HIV transmission with a parallel fact about "how HIV is not transmitted" jkaxarl

LANGUAGES Oh SbX AND AIDS IN NEPAL 497

Figure 2 Electron micrograph as icon. Detail of poster produced In VIU/Nepul uith supporl from \mh VR,ca. IW4. tardainaj, for instance through mosquito bites sharing a cup. sneezing and so on (see Figure 4). These misconceptions could onlj be anticipated, since the \er\ function of the messages was to introduce the idea oi \1DS and HIV transmission to Nepali people B) 1997. an astonishing range of people would quote this information in the parrotlike voice of school rote learning a testament to the degree to which it had drilled its waj into public conscious ness (Of course understanding or even acting on this information is anothei matter all together). Later versions of the "kasarl sarcka kasarl sardaina

498 (VLTtRAL AN'IHROPOLOGY

i o

Figure 3 From an educational Hip-chart produced In Save the ChildrenA .S. ca. IW6. "Whul does HIV mean'" The arrow indicates an elapsed "five to ten years. I he caption underneath reads: ' When the \tr> small HI\ \iruses enter I he hod\ it causes MDS. I his virus destroys the hod\ \s immune system. It has hten found that M1)S de\elops five to ten years after I he virus enters the hoclv. message replaced "how HIV is not transmitted" with the more practical "how you can protect yourself from HIV" [e(Jsh&[a kasarf hanchnef. This message required the invention of verbal and graphic cocks for reference to sexiul intercourse A certain struggle over Inns to balance truth with ttiste I.icts with morals is evident. SOUK- versions speak o\ "hodilj contact /sarir xamparka/ others refer to "having sexual contact with man) people

(dherai janSsanga youn sarnparka t,w/(/j/to 'unsafe sexual contact' [asurak
chit Y'lim samparkal or even sexual relations with prostitutes //'< sxihritimll

Liifcku hvaktilnnitsa/i^ii \oitn .sanihaiulhii/. Prevention, conconiitantK ranged
from use a condom to 'onl\ have sexual relations between husband and v lie ' Illustrators relied on certain conventions to code sexual passion (silhou> ettes ol embracing couples flames; see Figures 5 and 6). Sexual transmission ol HIV was equated with seVul relations outside marriage and visuall) coded through certain symbols associated with modernization (a woman in western clothes, booze bottles cigarettes physical touching between male and female figures removal of ctothing see Figure 7). whereas 'protection from HI\ was conflated with sexual relations inside marriage visually coded In s\mbols

LANGUAGES OF SEX AND AIDS IN NEPAL 49s)

f ijiure 4 Modes of transmission. I ppcr picture [clockwise]: "It is transmitted: when a woman has VIMS is pregnant; from pntstitulinn; from the I)1IKHI of a |HTsi»n with VIDS; when one needle is userl hj m.ii» people.' I.imtr piiluie. "It is not transmitted: In mosquito hiti-s I»\ shaking hands through f(MKl; In lathnc*, b\ hugging. ITiis is the beek page of an MDS education comic b M k culled Samayakn Vw^j.Second Edition l)-s. 2051 (L996). IVo« > ducd In the IN(.() P \ I ft \N ritten h> Vshesh Malla, illustrations In Y karam Maharjan.

5(H) ( T L T I R A I . ANIHROPOLOGY

ftrwr X

»ni*H

Hsurt 5 Fhe tnndom is saying: "Don't forget to use nit1, OK'' I In1 caption readl " I el'l he s;ili- from VIDS l i \ always usinjj a condom when having sexual contact." Mk ker produced b) IC H, with siip|)«rt from \ m l \ K ca, 1995, K.iilili Nepal. of family (presence ot children, domestic scenes woman in a sari, eating together, couple full} clothed; sec \ i Hire S). These codes were and still •ire the sub|ect ol discussion in re\ie\vs In the Information, l.dueation. and ( oiiinuinication ( omrniuce Should married couples be shown in bed together? Would this be meaningful to the Nepali ullagers who sleep on the floor? Does it make sense to indicate nudit\ to allude to se\ when villager] generally have sex u i t l i their clothes on? The "kii\<ui sarcha kasari sardaimi messages cast AILXS as an abstract question ol microbral transmission, a move which displaces but does not eliminate the fundamentally social lorm of sexual

LANGUAGES Oh Sf-..\ AND AIDS IN" M I'AL

Figure 6 ( over of pamphlel produced bj \V K OM. with support from \iiih \R ca. 1995 intercourse Ostensibh the posters in which the images shown in Figure*, and X appear simply report information about transmission routes hut thej do so. implicitly or explicit!) bj using J male actor s poinl ol view to differentiate between two distinct kinds of female partners the s.ile wife and the diseased prostitute An entire!) different strateg) was pursued b) AIDSCAP the USAID lunded program In keeping with I SAlD's free enterprise philosoph) MDSCAP took the route of. . essive social marketing private advertising agene) developed a campaign around a jaunt) cartoon character condom logo whose slogan w.is "let's wear a condom to drive awa> \1DS. a slogan slightl) catchier in N'e|i.ili than in English (see Figure 9). Named Dhale) Dai (dai means older brother and Dhal— shield' —is a brand of condoms marketed b\

;(P

CL'I l l ' R A L ANIHKOPOl.OdY

Iigure7 Details of illustrations depicting ways HIN is transmitted, lop: "from unsafe sexual contacts (from Suvedl ll>('7); Bottom left: "from sexual contacts: with someone other thun husband or wife poster on HI\ tranmission, NCAS< ca. I99i~96>; Bottom rifjlit: "froin se\u>il intercourse with a person infected with III\ (poster produced I>* \IU /Nepal with support from VniP \R ca. 1994). U. AID supported ag ), the character was designed as ,i "friendi) and "lun image that also had associations of strength and protection. The Dhale) Dai campaign was multipronged: posters radio jingles, and a IV commercial lor the general public a comic hook to be distributed to AIDSCAP's target group of truck d n \ e r s and a humorous educational film. (It featured a truck

LAM'I AGhS Oh ShX AND AIDS IN NEPAL

50?

Details of illustrations depicting «;i>s to protrct yourself from VIDS. l o p : " b \ limiting sexual relations to onl> those between husband and wife (from Suvedi I*>*>7>: Bottom left: "only h a \ e lexual contact between husband and wife (poster on H I \ transinissiun. N( VS( , ca. 1993-961; Bottom right (caption not shown): ' In not having sexual intercourse wilh strangers or with man> people (poster produced by U K

Nepal with support from \ m F \ R ca. 1994). drucr giving AIDS prevention advice to his goof) assistant, who tnuls (h.it. among other things condoms are useful lor carrying water for an overheated engine and can serve in a pinch tor an alternator belt). One advantage of an animated cartoon condom giving instructions on how he should be used is that hecan unroll himself onto thin air. He did so on prime-time TV evei \ evening.

(VLTURAL ANTHROPOLOGY

Figure 9 "Let's wear a condom to drive awaj MDS.' Dhalcv Dal, created bj Stimulus Velvet tisinjjfor \II)S( VIVNipaUa. 1994. There was of course a backlash to these informational campaigns Not a tew workers in AIDS organizations confided to me that the) had personal reservations about condom promotion strategies and moral!) neutral messages about sale and risky sexual activit) l'he\ like a number of urban middle class people I spoke to. felt th.it to promote condoms was to erase moral distinctions between appropriate and inappropriate sexual relations guest editorial in an English language newspaper argued that the onh thing people need to know about AIDS is that the> should tear it and that the) will be sociallx ostracized if the) get it (Malla 1997). The public health wisdom behind the informational campaigns was not alwa s appreciated b\ the public Io many at the receiving

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end, AIDS messages like the Dhaley Dai campaign evinced an unnecessary attention to unseemly topics. Even some AIDS workers felt that the message ought to be more specifically about disease transmission. They wanted a message that stuck to the facts of AIDS without bringing certain possibilities for sexual activity to mind. Coding the Facts of HIV/AIDS: English as Arbiter of Truth Yes, I remember the first time I heard about AIDS. It was in a quiz contest in school. They asked "what is the full form of AlDS?"{n) —A Nepali AIDS worker in her mid-twenties The development workers involved in AIDS intervention had to learn about AIDS themselves before they could do their job. Most of the workers I met described themselves as having "heard of AIDS" but as not having given it much thought prior to being hired. Because of this, the first phase of donorfunded AIDS programs was capacity building (the term used) accomplished by teaching workers in the NGOs what AIDS is, how it is transmitted, the social issues that make it a concern for Nepal, what the main AIDS awareness messages are, and the best strategies of communication. English is the appropriate medium for this information, in the perceptions of AIDS workers. The concepts that distinctively define AIDS, from virus to immune system to safe sex, are seen as transparently represented in English. Expressed in Nepali, these concepts can only be conveyed in explanations of one or more sentences or in translations that require neologisms constructed out of Sanskrit roots.26 Workers have to first learn the technical vocabulary in which the facts of AIDS are expressed in order to become AIDS educators. These English terms thus pepper communication about AIDS, despite workers' explicit efforts to render AIDS information in Nepali. It is as if AIDS (and AIDS intervention more generally) is an object that can only be seen through one particular lens, and the lens through which AIDS is discernible is English. For workers, an immune system is somehow more an immune system when stated in English than when explained as a concept in Nepali. It seems more concrete, more solid and precise. The Nepali term pratirakcha pranull is so technical and abstract few can understand it, while the more colloquial phrase bibhinna rogko kitSpu lacjne $akti (the [body's] power to fight the germs of various diseases) does not necessarily resonate with many people's implicit images of disease processes. The implicit idea that germs cause diseases will be meaningful, at different levels of precision, to some Nepalis, and entirely meaningless to others. How are these germs fought? What is the sakti, or power, of the body? The notion that the body fights off germs that cause disease has its own social history.in Nepal, a history that ties the notion itself to the West and to the forms through which Nepalis with differing degrees of privilege might encounter it. Some Nepalis learn about immune systems and viruses in elite English-medium schools, some memorize the term pratirakcha prapall as part of the rote learning science lessons in their village school, some

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hear about kitapu (germs, bugs) from health workers trying to convince them to build latrines. Concepts of germs, viruses and the body's immune system are no longer alien to Nepal, but they have an uneven presence and are elaborated with varying degrees of precision. They are held, moreover, along with other everyday concepts of the body and illness deriving from humoral, religious, and moral-supernatural frameworks. Take the word syndrome, usually translated in the AIDS literature as bibhinna rogko lakchanharu (the symptoms of various diseases) or lakchaa samuha (a cluster of symptoms). A simpler alternative term might be betha. a word used commonly, especially in rural areas, to refer to the condition of being ill, a word, moreover, that rather precisely suggests the notion of a condition of clustered afflictions that do not necessarily have a single cause. BethH never appears in English-Nepali dictionaries as a conceivable translation for syndrome, however. I remarked on this one day in a conversation with Dr. Bhadra, the leader of an NGO involved in AIDS education and a man who shared my interest in these problems of language. We had decided to organize a series of workshops with a handful of experienced AIDS workers to tr\ to produce a glossary of AIDS terminology for Nepali speakers, and my comment about the aptness of the word betha spurred Dr. Bhadra to use the workshops to widen what would count as a good Nepali translation of the technical vocabulary of AIDS. 27 In the first workshop, we laboriously worked our way through acquired, immune, and deficiency and had finally arrived at syndrome. Tea and biscuits had been served. Somewhat mischievously, Bhadra wrote syndrome on the board, writing betha next to it as if it were the obvious translation. With a bland look on his face, he turned to face the group. The participants were at first surprised, then uneasy. They shifted for a moment in their seats, then burst into discussion. Betha just doesn't fit (mildaina), one participant argued, because syndrome specifically means a consistent grouping of symptoms, whether or not the sufferer recogni/es them, while betha refers to the feeling of pathos and suffering that is part of being sick; it is a subjective view.2* Bhadra replied. "11 we're talking about AIDS and we have to use words that are hard to explain, then those words seem like they fit [milncjasto lwP'[n). He had put his finger on the crux of the matter: that AIDS workers have developed a sense that the foreignness of AIDS, as a disease, requires explanations that themselves convey an alien feeling. The others still felt that "it doesn't sound right" fsuhaundainaf. "When you say syndrome one kind of feeling comes into your head." a participant blurted out. "and when you say betha the feeling is different"!n}. Bhadra countered, "it doesn't sound right to us because we are immersed in information about AIDS. But if u e are talking to people who have never heard of AIDS, and never heard of 'syndrome' the question is. what do we say to make them understand"(n}7 Betha really did not sound right, as the exchange above makes clear, to these AIDS workers. One reason some of the workshop participants gave is that, as such a vernacular and very "authentically Nepali" word, it feels too

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507

emotionally compelling. In a strictly technical sense, it is no more nor less accurate than lakchap samuha as a translation lor the clinical term syndrome. When a group of AIDS workers insist that their gut feeling, as native speakers, is that bethd simply 'does not fit" the idea of syndrome, they are revealing the logic governing the translation choices that link Nepali and English, the dominant language of international knowledge. There is a language ideology at work here. It does not feel right to these speakers to place such a folksy Nepali word right next to a technical word in English. When English terms are translated into Nepali (thereby forming the terms in which most Nepali speakers will become familiar with concepts and vocabulary), the choice in Nepali is always for the more complex and literate forms. Rather than bending colloquial knowledge toward the authoritative language, a move that would make the distance between ordinary Nepali life and the world of international knowledges bridgeable, a literate form of Nepali is inserted as the necessary intermediary between colloquial "folk" language and international language. It is not surprising that a technical vocabulary developed in one language is borrowed by speakers of another language to express concepts for which they lack a lexicon. English in AIDS work seems, at first glance, like a simple case of borrowing: why would there be a word in Nepali for retrovirusi Sociolinguists distinguish between this kind of lexical borrowing and code-switching, where a shift between two languages in the speech of bilingual speakers is triggered by features of the communicative context (such as the nature i)\' the relationship between speakers, the institutional domain of communication) or where the switch itself can be a performative tool that manipulates the meaning of the communicative context (by indicating a level of formality, expressing social solidarity, or conveying emotion, for instance).29 These insights into lexical borrowing and code switching only take us part way toward understanding the significance of the language issue in AIDS education. More recent thinking has come to question whether languages are best conceptualized as codes with distinct boundaries separating them unequivocally from other languages (Irvine and Gal 2000). Shifts of register within the same code, the borrowing of terms, and switching between codes can all be seen as part of a continuum of linguistic practices through which identities and the boundaries of communities are experienced and marked. Thinking about language in this way challenges the idea that talk simply "takes place" in the already fixed array of communicative settings in a larger context. It suggests a more dynamic relation between text and context.Vl Linguistic practices can both express the tensions created b\ social difference and stratification and serve, potentially, as a meaningful tool for retiguring the understanding of social positions. More than that, context must be understood not merely as the immediate situation in which speakers interact, but the larger political-economic structures that organize national and international relations (Gal 1989; Kroskntv 2000; Silverstein 1998). "Languages." writes Michael Silverstein. "are only relatively stable . . . outcomes of dialectical valorizing processes among populations of people" (1998:402). Languages are caught up in institutional projects

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of political orders on scales ranging from regional and national to the global, and the "locality" of any language community is the product of a eontrastive understanding of what it means to participate in a language community, given that linguistic usage is inevitably ideologically charged as an index of social identity. As Silverstein puts it, "languages and their locally recognized variants become emblems (iconically essentiali/ed indexes) of their users' positions in a shifting field of identities" (1998:411). Code-switching is a social practice that "must be seen as the socioculturally meaningful creation and transformation of interactional context through the use of entextualized forms" (1998:413). The question we must ask, according to Silverstein, is how does a group constitute its cultural mode of allegiance to particular linguistic forms? AIDS awareness education and the sex education that so often goes with it are particular "entextualized forms." They are, in practice, communicative events that actually aim to transform "interactional contexts" by creating news forms of awareness. Recognizing this, we can better appreciate the social complexities of word choice. The use of English has important social implications in Nepal. Nepali is preferred in most situations, even by Nepali speakers who are fluent in English.31 Nonetheless, in the speech of the most educated urbanites code switching into English is very common, and at least some English words or phrases figure in the ordinary speech of a range of people. Some code switching feels right. But to code switch into English "unnecessarily/' as people put it, when speaking to another Nepali speaker is interpreted as an arrogant move to demonstrate superiority. This is because command of English is strongly linked to social privilege, indexing as it does an educational background that only money can buy. Code switching also occurs because English is associated with certain domains of experience: world popular culture, technical and scientific knowledge, modern forms of administration, school-based information. Access to these domains is also organized by social privilege. The development-related work of Nepali officials, planners, and staff is pulled toward English not only because the goals, activities, and concepts are named in English but also because English is the language of accountability to donors. Poster slogans, training manuals, pamphlets are frequentK designed first in English, only later to be worked up in Nepali, because it is ,ilwa\s necessary to be able to show the donor agency what the organization is doing. Proof o\' accomplishment to non-Nepali speaking donor consultants and decision makers always overrides the work of formulating texts in Nepali or minority languages in Nepal. In this context. AIDS' workers are more than just diglossic individuals who move between languages as they shuttle between speaking to the people they educate and the donors who determine their programs. Rather, they actively mediate multiple contexts by mediating languages. In doing so. they are establishing the sociolinguistic pathways that will convey information.

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Learning AIDS to Teach Prevention In no other health education initiative is the public asked to pay so much attention to the scientific and medical terms of explanation. Posters laying out "how HIV is transmitted" begin the job, but it is in training workshops that the full body of AIDS information comes to life in the interaction between facilitators and participants. In these training sessions, people such as community health workers, family planning motivators, local Red Cross volunteers, students, and members of the police and military are brought together to be taught about AIDS and STDs so that they can raise awareness among others/12 Such programs offer a socially acceptable—and arguably, necessary—displacement of the potential stigma of receiving AIDS information by framing the participants as teachers of others, not as people themselves at risk. That these training sessions must devote much time to both basic health and sex education underscores how much even "simple'-' AIDS information rests on the assumption of a particular background frame of reference. In these workshops, a standard repertoire of topics and participatory exercises is adapted and pitched to each audience, depending on their presumed level of education and social background. This repertoire includes the following elements. (1) explanation of the acronyms AIDS/HIV and of the distinction between HIV infection and AIDS: (2) definitions of antibodies, immune system, and opportunistic infection (sometimes preceded by an explanation of "germs" and the concept of disease caused by microorganisms); (3) explanation of the "test* for HIV and the "window period" before seroconversion when the test may not be accurate; (4) how HIV can and cannot be transmitted; and (5) introduction of the concept of sexually transmitted diseases, their symptoms, and their treatment.33 Sometimes the social causes and consequences of an AIDS epidemic in Nepal are addressed. The remainder of the time in the training workshops is devoted to issues related indirectly to the sexual transmission of HIV. The problem, as the programs conceive it, is how to get people thinking and talking about sex so that they will be able to talk to others about sex. The platform most often chosen (and this is the sixth standard element) is a discussion of body changes during puberty, which leads to (7) an account of the physiology of reproduction using diagrammatic line drawings of the male and female reproductive organs and, often, an account of the menstrual cycle and conception. This sets the stage for (8) discussion exercises designed to explore values and feelings around sexuality. In training sessions I observed, many participants were learning for the first time about fertilization, the physiology of the menstrual cycle. and a category of diseases known as "sexually transmitted."u HIV and sperm— two things described in Nepali as "so small the eye cannot sec them"—were often conflated by trainees, as were descriptions of fertilization and infection. For many people it was hard to take all this in and remember it clearly afterward, a problem of which the people who organized these training workshops were quite aware. The touchstone of AIDS education is the unpacking of the English words the letters in AIDS and HIV stand for, and the translation of these English

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terms into Nepali. One of the points of these tangled unwindings is to inform people of the distinction between AIDS and HIV, presumably so that people can grasp the difference between being infected and being sick. Yet it is precisely the HIV/AIDS distinction that makes their communicative task harder than it need be. "After all, when we teach about TB," Bhadra mused in one of our dictionary workshops, "we don't teach people the Latin name of the bacillus. It would be easier if we could just talk about the AIDS germ Jaid.sko kitanm]." Why, then, do AIDS workers insist on teaching the HIV-AIDS distinction? For one thing, the technical competence that qualifies one to carry out AIDS work must be demonstrated by continually marking the HIV/AIDS distinction. NGO teachings are actually policed. Their upstream accountability to the international donors who sponsor their work requires that they be factually accurate by the measures of accuracy set elsewhere. Looking downstream, as it were, to the people they are supposed to reach. AIDS workers correctly perceive that the tcchno-medical terms in English are what AIDS "is." To collapse AIDS information completely into colloquial Nepali would erase most of the concepts they are told define AIDS. Moreover, though it would smooth many immediate difficulties of communication, it would do so by creating an unbridgeable chasm between the internationally established facts of AIDS and Nepali vocabularies for knowing it. It is by hanging onto the vocabulary of technoscience that Nepalis variously positioned along a steep grade of inequality can rappel themselves up this cliff face to stand, as it were, on the flat plains of internationally established truth and fact. Much AIDS awareness work that has taken place in Nepal could be criticized for spending too much energy producing complex, overly technical medical explanations of HIV transmission and AIDS, materials that provide a kind of knowledge about AIDS that few can connect to their own real conditions of vulnerability to HIV infection. It could further be argued that this shows just how out of touch urban elite N(>() personnel are with their less privileged compatriots (many of whom use languages other than Nepali, anyway). I wish to place alongside these valid criticisms a somewhat different point, not as an apology, but as an insight into the processes that structure the context in which any AIDS education in Nepal must do its job. Science and all other modern epistemologies organi/e immense arenas of life and thereby demand recognition and invite emulation, Nepalis at all levels are well aware of the asymmetries that govern which knowledges and values are. in effect, suitable currency in global circulations. This is the definition o\' marginality: to be positioned as the exception, the deviate, the parochial, the remnant, or the merely local in the face of the universal.As The knowledge of science is the magnetic north toward which all compasses are now compelled to point, no matter which forests of meaning people may be dwelling in. This magnetic pull might help account for the evident delight those receiving lessons about AIDS find in eagerly asking how long HIV can live in a drop of blood outside the body, whether HIV originated in green monkeys, what the precise period o\ time between infection and seroconversion is. and

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whether it is true that the cure has actually been found. The enthusiastic appetite for this kind of information, and the precision with which such questions are asked, is remarkable, and although it surely is driven by the desire to avoid another set of questions about AIDS (like, What about my risk in my sexual relationships?), the pleasures of engaging the obscure facts of a science-for-itsown-sake should not be underestimated.™ The questions themselves indicate that the askers already know that these arc askable questions. From the perspective of AIDS workers, there are several reasons why it is difficult to draw the line at the minimal necessary information. One mundane reason is that the most efficient thing for an understaffed, underskilled, and underfunded organization to do is translate existing English-language materials on AIDS directly into Nepali. But the principles of health education are also involved. To follow the health education guideline of using terms people can understand is to violate the mandate to provide accurate information. In training workshops I observed, more detailed information was presented as a response to real or potential misunderstandings of basic points. Even more fundamentally, it seems that much of the information only makes sense as a whole package. As we have already seen, once you begin trying to explain what HIV and AIDS "are," you are on a slippery slope from public health messages to molecular biology's understanding of T-cells and retroviruses. The simple metonymic relations that make it possible to condense AIDS information in the first world do not work well in Nepal, where a part, such as a word like immune system, does not stand so easily for the whole idea of health (as Martin 1994 argues it does in the United States). If the truth of AIDS is contained within the language of science and medicine, then is not this language necessary for any kind of understanding? Workers themselves have to struggle to assimilate the technical information that defines AIDS in much the same way that participants in their training sessions do. Dr. Bhadra. for instance, complained that many AIDS workers are under the impression that seroconversion is a phenomenon unique to HIV/AIDS, and that a single exposure to HIV will immediately and :ilwa\s infect a person. AIDS communication is a catch-22: to actually translate the information on what AIDS "is** is to provide information that is hard for Nepalis lacking specific training in biology or medicine to understand; to bracket this information and the terminology which is its vehicle off from public view is to ghettoi/e these same people in a restricted prison of limited understanding. AIDS workers experience this dilemma as much in their own training as in their educational practice. Indeed, the line between an AIDS educator and the public to be educated is always tu//y because, as noted earlier, most workshops and sessions on AIDS arc teaching AIDS to people—be the\ family planning motivators, community health workers, or peer educators—who are then supposed to educate others. Every student of AIDS is also positioned as a teacher ol AIDS. The effect is that, far from sharpening the dichotomy between the knowers and the believers, AIDS education creates gradations of knowledge, good

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enough knowledge, semi-useful knowledge, incomplete knowledge, fragmented knowledge across shifting layers of communication. Through practices ot word choice, translation, and explanation people actively mediate relations between knowledges along this continuum. I have dealt thus far with information about disease, the part of the AIDS awareness message where the problem of communication is assumed to be only a matter of getting the facts to people. I have shown that it is not so easy to package "the facts" of AIDS in Nepali. Efforts to do so require translations and code-switchings that set up socially charged nodes of connection that bring some people in Nepal closer to the facts than others. This is the process through which a set of facts about the body that have stabilized in one context of knowledge production become meaningful to people in another context. Through this process the possibilities for communsurability become organized social realities. Next let us turn to the sex education component of AIDS awareness messages. Here the mediations between knowledges of the body have a different tenor. When it comes to sex education, it is an even more difficult job to graft knowledge about sexuality in Nepal to the international language in which the official facts of "sex" come packaged. This is commonly thought of as a matter of competing value systems, not competing truth claims about the body. I will suggest that the problems of sex education are actually much like the problems of AIDS education I have just discussed. Sex and the Necessity of "Unnecessary Talk" Consider the plight of a high school health teacher, who told me: I might be able to talk easily about MLI But I can't say it in Nepali. 1 can't say it in front of other people. 1 am educated but still 1 can't say these sorts ol things But in English I can say anything without embarrassment. When I teach about the reproductive system and about sex I don't use a sinulc Nepali sentence. My culture makes it difficult forme fn}. AIDS workers say much the same thing: "sex education" is "difficult" due to "culture," but using English words makes it possible to overcome embarrassment. They should know. Whereas teachers only have to point to ;i diagram of the male and female reproductive organs as part of a health lesson. AIDS educators have to speak repeatedly of sexual intercourse and condoms and allude to couplings that fall outside social approval. Recourse to a second language always serves nicely to defuse the emotional charge of certain words in one's mother tongue, ol course, so it is not surprising that educators find English words less embarrassing. This observation alone, however, does not fully account for what happens in the oscillations between English and Nepali in discussions of sexual matters. Speakers are grabbing English because of its capacity to distance and saniti/e. yet in doing so they are also taking possession of it to create new possibilities for discussion.

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AIDS prevention templates contain unexamined assumptions about what constitutes sex education and what purpose it should serve. The frank and open discussion of sexual feelings, choices, and behaviors is valued along with the provision of accurate information. What health educators mean by accurate information is a biomedical understanding of reproductive physiology (how the body works) that is rendered through the delineation of pathology (disease) and normalcy. What counts, nowadays, as sex education emerged out of a fusion of the endrocrinological discoveries of the 1920s and 1930s, the political agendas of social purity, eugenic, and contraceptive movements, and the crystallization of sexuality as an object of a new science of sexology (Clarke 1998; Weeks 1989). Sexual knowledge began to be made in a distinctive new way, according to Porter and Hall, from around the 1880s. It "endeavored to escape or avoid association with pathology, individual or social" (1995:154) and "at least in intention, however compromised, set [. . .] out to apply the rigors of scientific rationality to a highly emotive area" in a way Porter and Hall say "provided a radically new way to make, unmake, and remake sexual knowledge" (1995:177). Medicalized, it became possible to discuss sexual matters with clinical detachment. A nameable, knowable, manageable domain called "sex" began to take shape in European and North American thinking, in part through the discourses of sexual knowledge (Foucault 1978; Porter and Hall 1995) and in part through the social changes associated with industrial capitalism that created conditions for the experience of a sexualized "personal life" (Caplan 1987; D'Emilio 1997; Ross and Rapp 1997; Weeks 1989).37 Contemporary models for AIDS education efface the historicity and cultural specificity of this understanding of what "sex" is. "Sex" is taken as a self-evident domain of human experience that can be addressed in the name of public health through sex education. For Nepali AIDS workers, merely finding a culturally acceptable way to raise issues and name body parts is not enough. They are involved in establishing the ground for a public discussion of a problematic discursive object called 'sex."38 Importantly, to speak about the difficulty of talking about sex they have to use the word sex in English, for there is no corresponding term in Nepali. AIDS workers and others note this as a sign of the disjunction, or nonfit, between the international (Western) framework and a sensibility they identify (somewhat misleadingly, given Nepal's social diversity), as Nepali. "To talk about sex in Nepali is absolutely unimaginable," I was told laughingly by a Nepali friend here in Canada when I posed to him the questions I tackle here. "It is like me"—an engineer—"trying to talk about geomorphology in Nepali. It simply can't be done." His comment, like many others I heard to this effect, shows the extent to which knowledge can appear coterminous with the language in which it comes packaged. AIDS workers are bending the word youn to serve increasingly as a synonym for "sex" in phrases such as sex education (youn tikcha), safe sex (surakchit youn samparka), and sexually transmitted disease {youn rog). They have

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debated which term for sexual intercourse would be both intelligible, clear, and polite enough to use in public, settling in the end on xoun samparka (sexual contact). None of these terms were common parlance, I was told, prior to AIDS prevention efforts. Now they are increasingly familiar terms to many educated urban speakers. More than one person insisted to me that youn does not mean sex in the same way the English word sex means sex. Such a comment can only come from someone who can hear and use English in a certain way. It seemed (to me) that these speakers inflected the word youn with the meaning they attributed to the word sex and, indeed, the ability to understand these AIDSrelated neologisms depended on this hybrid interpretation. What about those Nepalis—the less educated, less cosmopolitan—who do not already know how to talk about certain sexual matters in English? From the reports of frustrated AIDS educators and my observations of the confusion of some of their students, it appears that the neologisms undergo semantic slippage when the word youn cannot reliably conjure up its "proper" translation as sex. What safe sex (surakchit youn samparka) means to your average villager, one experienced AIDS educator commented wryly, is finding a place to have sex where no one can see you. Similarly, AIDS educators report people thinking that \Y>«/I rog (literally "sex disease" or STD) must mean excessive sexual desire, or diseases that arise from the heat of excessive sexual activity, or possibly even problems like premature ejaculation. Many Nepali speakers do not place the boundaries around a domain of "sex" in the way AIDS education requires. Preoccupation with word choice has been AIDS workers' response to this problem. In Nepal the question has been how public acceptability could be reconciled with clarity of communication. The most common polite, colloquial ways of referring to sexual intercourse are context dependent circumlocutions about "that" [the particle u\. Other common ways of referring to coitus include "contact" and "relations" and "the work which happens between husband and wife." (Sex between men was not addressed in Nepali AIDS prevention efforts). In the NGO review committee for educational messages, these phrases were deemed too vague and ambiguous to be suitable for AIDS pamphlets and posters, as was the very colloquial term laspas, which means, basically, "fooling around." Early AIDS prevention messages sometimes pointedly attributed HIV transmission to "going outside" [biihira ji'inuj or having sex with prostitutes, an approach quickly squashed by Am FAR on the grounds that it is both inaccurate and judgmental. Not surprisingly, the educated elite, mostly highcaste Hindu leaders of AIDS programs were drawn toward formal, literate, sanskritic terms like samhliog, youn kriyi), rati krixj. maithun even while some workers acknowledged that such words were not readily understood by many Nepali speakers.v' They ended up settling on youn samparka, even though they admit it too is odd. if not entirely incomprehensible, to many of the people they address. I was told that this word was not commonly used before the advent of AIDS programs (that is. before the early 1990s). Nonetheless it was clear to me that the sheer repetition of this term, not only in AIDS messages themselves, but in a ran^e of more public discussions of sex that developed in tandem with

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AIDS publicity—such as Dr. Bhadra's sexual advice column in Saptahik, a popular Nepali language newspaper—was quickly making it the word for which people exposed to these messages would reach. Again, this is the paradox of AIDS communication: the terminology that opens new possibilities for speaking about sex for some speakers makes the topic obscure for others. If, in the perceptions of AIDS workers, vocabulary is one obstacle to talking about sex, the other is what they refer to as the problem of "acceptability." AIDS workers experience the problem of acceptability as both an external (interpersonal) and internal (subjective) struggle. Their programs are rarely welcomed. School principals, village officials, carpet factory owners, media censors and other gatekeepers have not only resisted AIDS awareness activities, but have sometimes been vituperative toward the workers themselves. In one case I heard of, dogs were set on the hapless outreach worker: another man was hit in the head with a rock during a street theater performance. But these attacks aside, AIDS workers also have to struggle with their own feelings of discomfort and resistance. They, after all, are the ones who have to stand in front of groups of strangers and talk about how to put a condom on an erect penis. One unmarried woman in her early twenties described to me the bone-chilling mortification she felt when, soon after starting her job, she was required to discuss a list of sexual words w ith her male colleagues. Of a similar experience in her training another young woman said, "everything inside me said, 'don't say this.' but it was my boss asking me to say it." A middle-aged man who worked as a planner in an INGO mused that development outreach workers want to be seen as role models in the communities in which they work, and that speaking about sex. AIDS, and condoms is problematic because they feel it will undermine the respect they feel people ought to have for them. As men and women, workers experienced gendered dilemmas around respect and respectability. These reflect what the problem of talking about sex actually is: a problem of context rather than topic. AIDS workers themselves sometimes pointed out that in same-sex, same-age groups, sexual matters are more freely and easily discussed. AIDS education requires people to discuss sex in public situations organiz.ed around differences of status. These include classrooms, clinics, professional situations, and development outreach work. AIDS messages always carry a flavor of the official civic legitimacy of development. In Nepal, anything that is framed as an issue of "awareness"—as AIDS has been—brings connotations of status differentials marked through idioms of education, understanding, and development (Pigg 1^2). To pass on AIDS awareness information is to be caught up in these implications, thereby making the very act of AIDS education something that marks a communicative context as somehow public and official.1" In public contexts where<here is a status difference between speakers it is especially transgressive to talk directly about sexual matters. Respect is demonstrated through acts of restraint: deference is embodied in acts of holding back and keeping silent. It is worth noting how Nepalis refer to talk of sexuality when it does occur in these contexts. It is condemned as nachnhine kuril.

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unnecessary talk, and most of all, it is chd(Ja. Chada talk is talk that \ lolates the accepted constraints, talk that roves, as it were, in directions it should not (on women who are labeled "chads," see Liechty 1994a:232). Thus in Nepali, not being able to talk about sexual matters in these contexts extends to not even being able to name in Nepali that which you cannot talk about except by labeling it as a breach of norms. Hence the problem faced by progressive AIDS workers. There are patterns of appropriateness governing who may speak in Nepali about sexual matters, and how, when, where and in what register they might do it. Of course it has always been possible to speak in Nepali of coitus, fertility, sensations, genitals and other body parts (and things you can do with them)—the nondiscursive referents that might be indexed in a discussion of sexual matters. There is, moreover, a discursive universe that constructs lust, attraction, desire, erotic aesthetics, that labels sexualities, and that organizes sexual relationships into socially resonant categories. Nepali is as rich as any language in terms, be they euphemistic, metaphorical, vulgar, graphic, loving, or humorous. The patterns of these ways of speaking need to be researched, for they have received no attention in AIDS prevention circles in Nepal despite the incessant preoccupation with how to talk about sex. In AIDS prevention discourse in Nepal, these nuances are erased by generalizations about stigma, shame, and cultural prohibitions (Pigg 2002). English enters into the patterning of Nepali languages of sexuality, disrupting them but also extending them. People I spoke to saw the intensification of public attention to sexual matters as recent, and their reflections about it often centered on the question of the relation between a traditional Nepali society and the modernizing influence of the West. Westerners are portrayed as "open" in their ability to speak without embarrassment about sexual matters, a characteristic regarded with considerable ambivalence. Nepali social norms, and the Nepali language itself, are portrayed as deficient vehicles for sex education by Nepali AIDS workers, for they are constantly forced to compare what they are trying to communicate with what they know they are expected to communicate about sex. Recall that in Nepal. AIDS and sex education modules are adapted from resource materials in English. Despite efforts to develop and cross-test these materials internationally, these templates often incorporate discussions of concepts like sexual identity that do not have correlates in Nepali, or contain exercises designed to foster assertiveness skills for sexual decision making that presume certain styles of verbal interaction that may not easily transfer from one society to another. The information presented in these sex education templates has an authoritative aura: These are the tacts of life, if you will. English is felt to be more precise, sanitized, and technical, and therefore more suited to the proper fin both senses of the word) communication of this information. English words relating to sexual matters, including the category term sex itself, tend to form the core vocabulary for AIDS workers, especially when speaking among themselves. The Nepali "translations" of these terms are for their target groups and their posters. In the practice of AIDS workers. English

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terms are as necessary to the "necessary information" of sex education as technical/medical terms in English are to explaining the facts of AIDS. English gives AIDS workers and their audiences words like safe sex. sexual satisfaction, oral sex, anal sex, sexually transmitted disease, pedophilia, sex worker, and homosexuality. Whether or not these concepts can be articulated in Nepali, these English words are perceived to have a cool, technical neutrality. What the English words do that the Nepali lexicon cannot is to objectify sex by turning it into something you can point to and talk about at arm's length. English extricates sexual matters from the embedded emotional intimacy and moral density that can make mention of sexuality exposure of self. Those Nepali speakers who can code switch into English understand the English word sex to mean precisely that possibility of direct public discussion of acts, body parts, and feelings that could otherwise only be addressed indirectly, if at all, in a public context. English, in this sense, is the language for talking about sex because it provides a discourse that operates by bracketing off an object called sex and then placing it in relation to—no longer in and of—social relations, and, importantly, morality. Compacted in the very vocabulary of sex in English is the sexological tradition from Ellis and Krafft-Ebbing, to Masters and Johnson, to Dr. Ruth. Foucault would place it within a larger "incitement to discourse" that "set out to formulate the uniform truth of sex . . . in an ordered system of knowledge" (1978:69). For Nepalis, this particular truth comes in the form of English, and when it is translated into Nepali, it no longer seems ordered in the same way. I purposely risk an overgeneralization in saying that this is true "tor Nepalis." The vast majority of Nepali citizens have very little exposure to English because their access to formal education and international media is limited by rural isolation, poverty, or both. We social scientists know very little about languages of sexuality across the social spectrum in Nepal, and. at this writing, almost nothing about how people in diverse social locations hear and make use of the AIDS and sex education messages they might hear. Exposure to and familiarity with English clearly follows the fissures of social inequality. But it is a mistake to approach these questions of language by dividing Nepalis into those who do use English and those who do not, and to assume that my observations about language ideologies guiding AIDS workers are irrelevant to the rural poor. AIDS prevention work draws people into certain ways of speaking about sex and it calls existing ways into new relations. The language practices of elite AIDS workers are supported by a larger development apparatus that extends the mediating strategies they choose by formalizing them in institutional practice. Following the reflections, of the AIDS workers and others with whom I spoke, I see English as a signpost for an emergent, but unstable discourse of health and hygiene around sex. To explore how this discourse takes shape and the positionings it makes possible, I turn to two extended examples of practices of translation and code-switching in contexts organized as sex education.

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Finding the Words My first example is an exercise used worldwide in AIDS related training programs.41 The Sexual Words Exercise is used in Nepal as a "desensiti/ation" exercise or an "ice breaker" to help trainees overcome shyness in speaking publicly about sex.42 A list of "sexual words" are presented to trainees. What counts as a "sexual word"? The Sexual Words Exercise typically elicits further vocabulary for some or all of the following terms: sexual intercourse, semen, ejaculation, penis, vagina, masturbation, orgasm, breasts, anal intercourse, oral sex. kissing, erection, buttocks, condom, homosexual, bisexual. When participants are given the work sheet listing these terms in Nepali, it is sometimes necessary for the facilitator to define the Nepali words for which synonyms are to be found, since, as we've seen, the Nepali terms chosen as the "proper" translation of the English words are not necessarily widely understood (for instance, samlihga as a term for homosexual)^ When the trainees can be presumed to know English, the list is often presented in English or English paired with the formal Nepali translation that has sedimented as "the" word through the process of developing educational materials. Presented with this list, trainees are asked to list as many synonyms as they can. Sometimes, to make this awkward task a bit easier, participants arc asked to begin with "formal" synonyms and then move on to "slang." categories also rendered as "acceptable" and "unacceptable". This allows people to present themselves as quoting, not really voicing, vulgar terms. Facilitators encourage, cajole, and goad participants into writing the words offered down on large sheets of paper for all participants to see. Afterwards, these sheets of paper are often taped to the walls and remain up as a kind of sexual wallpaper for the remaining days of the training. The mood in the room is invariably intense during this exercise; there is as much laughter as there are demonstrations of shyness. To speak many of these words aloud, often in groups consisting of both men and women, is deeply embarrassing for some, titillating or funny for others, and for still others, just peculiar. That this exercise is conducted in the context of a training session makes many participants, especially women, particularly uncomfortable. To be asked to call out slang terms for sexual intercourse requires trainees to reveal themselves as a person who "knows" these words in a context which otherwise calls for a very different presentation of self. Two rationales for this exercise are offered to trainees. One is that if people are going to become peer educators, or health workers providing AIDS prevention information, they need to overcome (i.e.. become "descnsiti/ed" to) the emotional charge of these words. Being forced to say. hear, and read them will make them mundane, or at least toughen people up enough to use them. The other reason given is tKat educators need to be aware of the range of words people they talk to might use. The exercise is therefore sometimes presented as an elicitation of the slang of particular subgroups. Some NGOs took care to collect the lists generated by trainees of different backgrounds (the police proved to have an especially rich vocabulary). Despite this meticulous attention

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to the overabundance of words in Nepali, I never heard an AIDS worker or peer educator actually use any but the standardized word for which the synonyms are elicited. Informal or slang terms are kept firmly out of the newly formed linguistic repertoire for AIDS education. The exercise presents sex as a series of decontextualizcd fragments. It offers body parts, not persons; sexual acts, but not sexual relationships. Because this exercise is arguably the most visible symbol ol "talking about sex" in Nepali AIDS intervention circles, the clear medicalization of sex it fosters is significant. To use these words is to "talk about sex"; to talk about love affairs. mistresses, or marriages is not "talking about sex" in this discourse. AIDS information tends, more broadly, to be presented in this sort of abstracted, depersonalized language of sex rather than in a grounded discussion of the forms of sexual encounters and their social meanings. The legacy of Western sex surveys, with their attention to acts and frequencies, is evident. For AIDS workers who feel it is necessary to be nonjudgmental in communicating about sex for public health purposes, this language offers an escape from the thoroughly moralized terms Nepali would otherwise offer for the discussion of sexual relationships. This Nepali vocabulary pertains to relationships, not acts, and it systematically conveys the power relations between men and women via the moral connotations of the positions it names. In concert with many of their colleagues worldwide, some AIDS workers in Nepal argue that AIDS education is socially transgressive at its very core, and that exercises such as this one help break through the silences many opponents of AIDS education use as an excuse for doing nothing about AIDS. But more commonly facilitators and participants ask, pointedly, "yo garda ke phaida?" (What is the point of doing this?) Their facial expressions convey their distaste. Some AIDS workers argue that far from being a "desensitization" exercise, as claimed, it actually re-sensitizes people to a charged vocabulary by forcing them into an extremely uncomfortable position of uttering and hearing words that should not be mentioned. An exercise such as this lends itself to subtle misuse as an excuse for men to talk dirty (although no one ever said this outright to me). There is no way to "desensitize" these words, these AIDS workers claim. The repetition of the Sexual Words Hxercise in training after training dangles the possibility of a sanitized discussion of sexual matters for the purposes of health. The vocabulary list, with its focus on specific words, is made to represent what a frank and open discussion of sexuality would be like. To say the words is to be frank. To speak of sex through the apparently gender-neutral grid of sexual acts is to be nonjudgmental. In the translation of "sexual words" from a standard list in Hnglish into its execution as an "ice breaker" exercise in Nepali, however, the sexological frame, with the distanciation it can create, does not reliably survive. Nepali words do not conjure the medicalized frame as securely as does English. The words do not lose their emotional charge, but the exercise itself enforces an image of a saniti/ed discourse on sexual matters that could and should exist. The image and attractions of this discourse extended beyond the closed rooms in which these specialized training sessions

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were held. We see it in the mass media on a controversial radio show that allowed listeners to phone or write with any question they might have about sex. This show is my second example. Teaching People about Their Bodies Imagine, if you will, the stir that was caused in Kathmandu when, in 1997, an FM radio station started airing the "Hotline" on which a suave DJ invited listeners, in typical code-switching fashion, to write or phone "in case tap&iko kunai pani question cha bhane, no matter how difficult, how embarrassing, how bold it is, hamilai lekhnos post box number 8559" [In case you have any question, no matter how difficult, how embarrassing, how bold it is, write to us at post box number 8559]. Listeners flooded the show with calls and letters to be answered by the guest expert. It quickly became one of the most popular shows on radio. It also quickly became the target of vehement criticism from many officials in broadcasting, family planning, and development education who felt that answering listener questions about their practices of masturbation, their homosexual encounters, pleasure in the marital bed, or HIV risk in oral sex could not possibly have anything to so with the message of AIDS prevention (Pigg 2002). A debate quickly formed. Was the show pornography or education? Did the show violate standards of broadcasting decency under the guise of AIDS prevention? Pressure mounted to ban the show; fans and defenders of progressive sex education rallied to support it. Eventually its format was modified so that there was less listener participation and more didactic control from the studio. Too many listeners were writing in with questions about sexual activities that gatekeepers had been claiming do not take place in Nepal. Begun in March 1997 as a minor experiment with the idea that AIDS prevention must address sexuality in the broadest terms, the show was initially spearheaded by AIDSCAP and sponsored by Contraceptive Retail Services Ltd. (CRS), a previously obscure USAID-affiliated company charged with the commercial marketing of contraceptives. The public mission of AIDS prevention was mixed with commercialization and private enterprise from the start in the Hotline. The Hotline show extended the characteristic broadcasting style of FM radio—a style that featured lots of English from DJs, a preponderance of western pop music, and a heavy reliance on phone banter with listeners—to a weekly "sex education" show with an ostensible public service mandate.44 The contrast to Radio Nepal's shows on the benefits and side-effects of family planning methods could not have been more startling. The talk segments, with their sometimes astonishingly explicit discussions of sexual matters, were thus framed, somewhat incongruously, by the hip international pop music ("pretty woman, walking down the street, pretty woman") on one side, and CRS's stock-in-trade ads for contraceptives ("Panther condoms, for pleasure and safety") on the other. These family planning ads were long familiar to listeners, but the Hotline aligned them with AIDS prevention by introducing commercial

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breaks with aphorisms such as, "If you are about to entertain between the thighs, remember! Condomize"{e}! The use of English on the show became a point of discussion in itself. It was clear that to attempt such a show exclusively in Nepali would make it impossible to discuss many of its topics, for to name many of these acts and desires in Nepali would be to transgress, unequivocally, all bounds of taste. It couldn't be broadcast. English, on the other hand, changed the tone, making these acts and desires seem more legitimate as a topic of serious public attention. Unfortunately, not everyone who wanted the information could understand English. The public education mandate appeared to conflict with the clear class connotations of a certain linguistic style. On the show, therefore, the DJ, the doctor, the callers and letter writers code-switched between English and Nepali, as they groped for the right words. Indeed, the more nervous and embarrassed a guest expert doctor became at a question, the more English he used in response. As weeks passed by in the summer of 1997, the list of doctors willing to be the guest expert shrunk, until Dr. Bhadra (whom we have already met in the vocabulary workshops) was the only one left to field questions. Over half the letters sent to the show in its first three months were in English, while callers seemed to prefer Nepali. The DJ and the doctor tried to follow the linguistic preference of the questioner, but often the doctor could only provide a technically accurate answer by using English terminology. A full analysis of this code switching would be another article. Here, I focus on how people involved viewed the issue of language choice itself, as it came up during interviews and focus groups I conducted.45 My first stop was the offices of Radio Nepal, whose top programming officials were among the most outspoken critics of the show, with the power to pull the FM station's broadcasting license, to boot. In presenting to me their objections, they pointed to what they saw as the egregious mixing of English and Nepali. (Use of English on Radio Nepal is restricted). "Who is being served by this?" one official wondered. "The English speakers don't need the Nepali and the Nepali speakers don't understand the English at all"{e}. The FM broadcasters need to recall, he admonished, that their signal can be heard outside the urban areas of the Kathmandu Valley by villagers. Calling the show "explicit—even perverse at times," this official asked rhetorically "does each and every person need to be informed about everything that can be called sex education"{e}? He was referring, specifically, to rather detailed instructions that had been given in Nepali on more than one occasion on techniques for maximizing sexual pleasure. The programmers at Kantipur FM, for their part, consistently presented the show as a "health program" and they enthusiastically justified their programming decisions by the.eagerness fans had to "know about their body" (Pradhan 1997; Saptahik 1997). In their view, the basic message about HIV transmission would not sustain an audience: "you have to address questions about SCJL or no one will listen. Radio Nepal doesn't have to worry about listeners, but we are a business"!n}. People do not think about HIV, so there is no

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point in talking to them about it, a programmer said. It is better to get people talking about their problems. "They don't realize that we have put HIV awareness in their minds"(n}. He accused Radio Nepal of denial: "if we won't talk about sex., when will we start talking about HIV"{n}? Consistent with this philosophy, he justified the use of English as merely reflecting the way listeners themselves speak. Though their signal can be heard in a 35 kilometer radius, he said, "our target is not the village and we have very few listeners there. They don't like all the English and foreign songs and they don't tune in"(n}. Back at Radio Nepal, however, another programmer opined that "we do need to give sex education but there has to be a limit"{n}. In his view, people were mostly getting "sexual feeling"{e} from the show rather than information. When I asked him about whether the use of certain words ought to be banned on the show, he replied that the sort of low-level words that "people in villages use to scold" should not be used. Instead, "educational words." like those in schoolbooks, would be preferable. Or better yet, sex should be talked about indirectly, in a roundabout way. In his view, the Hotline was much too direct in specifically speaking of male and female organs. None of the letterwriters would use those words if the DJ and doctor were not broadcasting them. "It is up to the anchor to find the clear way to say things indirect!) ."{n| he said. And because FM, unlike Radio Nepal, is allowed to use English in its broadcasting, they can use "English words to be indirect"!n}. The target groups will understand. "More English," in his view, "would make the show more educational and serious." Fans, however, begged to differ. Although among the many hundreds of letters the show received in its first three months of broadcasting perhaps half were written entirely in English, the show received consistent pleas to explain more things in Nepali because "this information is so important"!n}. Wrote one fan, "especially when it comes to talking about genitals lyoun ahgaj and STDs lyoun rogf it is hard for those of us with weak English to understand what in fact is being said"{n}. It was a common expectation among the middle-class people I spoke to that hygenic-sexological views of sexuality would uphold moral rectitude by emphasizing "how diseases are spread." The Hotline, in contrast, was born of the very different philosophy of public health, one that emphasizes the provision of medical information and services over moral judgement. Whether sex education was acceptable, or even possible, was much discussed among workers in AIDS, family planning, and reproductive health fields, and when asked, adults and youth also had much to say on the subject. What set of information would come to count, however, as sex education was being worked out in the mid-1990s, in part through focal events like the debate about the language in which sex education on trie Hotline should be conducted. Many things are happening at once with language on the Hotline, whatever the messages it may be conveying. The show models for listeners with some competence in English what a mediation between the "true" (English) language of sex and Nepali might sound like. It does so by stretching vernacular

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Nepali into the form of the English sexological language. The ccntrality of English may have important consequences tor the many Nepalis who cannot hope to understand even a few words of it, however, because it also informs the stilted Nepali terms that have solidified as the "true" translation of the hnglish words. The ideology of language attached to sex talk in English is transferred onto an emergent reworking of Nepali, so that speakers begin to speak a Nepali that can emulate the hcalth-and-hygiene discourse thought to reside in English. What is striking about the Hotline—aside from the fact that it staved on the air—is the way the sanitizing potential of Hnglish opens up a space for a public discussion of sex that then invites other uses and positionings. With the distancing effect of the discussion of sexuality in terms of health and hygiene comes new forms of discursive identification. The for-your-own-good didacticism of AIDS awareness that this medicali/.ation of sexuality is supposed to serve gets re-appropriated wi^h an almost romantic abandon in a cosmopolitan youth culture. The Hotline is but one piece of this wider urban, middle-class youth culture in which media images, international sensibilities, and new practices such as body-building, fashion, modeling, and dating interweave in what Mark Liechty (1994b) has called gendered self-fashioning. Laura Ahearn (in press) has shown that even in (some) rural areas of Nepal, youth are making themselves into an image of a romantic, modern self. Falling in love is associated with being modern, developed, successful, and independent. The medicalization of sexuality carried in the English vocabulary of sex education converges with other frames for sexuality, ranging from the gendered relations of kinship to commercial advertisings association of commodities with romantic love. The expansion of a medicali/.ed discourse about sex, partially linked to national development, occurs side-by-side with this increasingly se\uali/ed commercial realm, not to mention the actual commodification of sex in pornography and prostitution. This is the loose seam at which historically distinct concepts o\' sexuality are in the process of being darned together. The AIDS prevention agenda is tied to a certain kind of knowledge about sex. The international template for AIDS intervention assumes that "sex** exists out there in the world as a selfevident natural domain of experience and that the kind of information that would constitute sex education is an equally transparent truth about the body. The rationale behind the Hotline indicates how deeply this view structures the terms in which Nepalis encounter both AIDS and medical knowledge about sex. Listeners' questions suggest reasons why some people wish to enlist themselves in this knowledge. The mix of discomfort, outrage, curiosity, and laughing astonishment with which the Hotline was received make it clear that the discourse of sexual health-and-hygiene sits uneasily with other ways of construing discussion of sexual juatters. Rather than trying to understand the relation between these views as an oppositional one. in which Nepali cultural values will either hold ground or give way to scientific knowledge and the Western values thought to be compatible with it, it is more useful to pay attention to the sometimes awkward amalgamations

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and conceptual near-misses in everyday practices. English and the possibilities for speaking of sex or AIDS that are thought to inhere in it are woven into Hows of communication in Nepali. Code switching in an utterance is onl> the most conspicuous form of this intertwining. The movement between, say, the suggestions for learning activities for training programs on sexual health provided by the International Red Cross and the actual implementation of a workshop for adolescent sex education is also a movement between the facts of sex as encapsulated in English and their expression in Nepali words and through Nepali examples. In the actual juxtapositions of Nepali and English codes, in the translations between them, interesting new possibilities are created. If translating information—any view of what AIDS is—into locally comprehensible languages and forms is an objective, then it is important to understand that this translation occurs along discontinuous pathways and involves layer upon layer of codeswitching, borrowing, and revoicing. There is no line between two knowledges or competing truth claims. What happens linguistically and conceptually in this uneven middle-space between the facts established by international science and the ground of Nepali discussions about them matters because that is where people actually live. The interpenetration of languages is also a negotiation of the ideologies speakers hold about those languages, an experimentation with what they feel it is possible to say in those languages—a negotiation that leads speakers to formulate through speech the "what" itself to which talk refers. It is at these junctures that—to borrow Donna Haraway's words—"what will count as nature and matters of fact get constituted" (1997:50). Outside the Citadel, on the Periphery
science is simultaneously . . . a "particular story of how things stand" and . an important part of the institutions that are exerting particularly brutal forms o\ power worldwide at the end of the twentieth century. —Emily Martin. Anthropology ami the Cultural Study of Science The relation between science and lay or public culture has recently been re-envisioned by work in the anthropology of science that shows their mutual interpenetration. Martin (1997). for instance, uses the metaphor of the citadel to describe studies that examine science—the "culture of no culture" in Traweek's (1988) famous phrase—as a set of socialK organi/ed meanings and practices for engaging with the world. What lies over the ramparts'* Might the walls of the citadel be permeable? Who lives outside the citadel? Martin extends the metaphor of the citadel, and proposes other metaphors, in order to "link (he knowledge in the citadel and its manner of production, with processes and events outside, processes that may be distant or spatially discontinuous from it" (1997:136). As Martin puts it: many powerful collectives and interested groups dot the landscape all around the castle. Not only are they there, but they interact with the world inside the castle of

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science frequently and in powerful ways It is as if we thought ot science as a medieval walled town, and it turns out it is more like a bustling center ot 19th centurs commerce, porous in everv direction. [1997:135] This vision of "commerce" and "trade" between scientific "citadels" and various public "settlements" helps us envision multiple sites of agency and crisscrossing lines of influence. But what if those settlements are on the periphery of industrialization and populated by people speaking non-European languages? In what wa\s do the inequalities created by conditions of economic dependency, neocolonialism, and cultural imperialism alter the relation between the inside and the outside ot science? The ethnographic questions about the science-in-culture and culture in-science look somewhat different when posed from a location such as Nepal, about a specifically transnational dissemination of scientific knowledge, and in relation to a practice such as AIDS intervention. These additional questions are particularly important not solely because science may be "part of institutions exerting particularly brutal forms of power worldwide at the end of the twentieth century" (Martin 1997:133). Science may also be part of quests for improved life conditions, through specific technologies, including medicine and preventive health. Much of the thinking about science and the so-called third world has been dominated by agonistic caricatures of science-as-life-saving-knowledge versus science-as-epistemological-colonization. Debates about science and multiculturalism—which are often debates about whether there is something distinctively "Western" about science—too often err by treating the knowledge produced by science as postulates about the world that lend themselves to relativistic contemplation or to absolutist claims about unmediated reality. Much of the debate is structured around a remarkably naive and unselfconsciously colonial picture of a world carved up into discrete, internally coherent cultures contained within definable territories (for instance. Harding 1998). Certainly in both the practical field of international health and in the medical anthropology associated with it. too much is taken for granted. We are left contemplating the gap between indigenous frameworks and biomedically grounded public health prescriptions, a perpetual binarism that leaves us either rescuing "indigenous knowledge" (as technique or as meaning) or trying to rationali/c it or append it to science. In place of these discussions of "cultures" (imagined as unproblematically unified worldviews) we need ethnographic research that considers the uneven middle ground where things actually happen (Rapp 1993). Phis perspective requires, first, a shift in how we think about the thinking of people in that vast space we call the third world. Instead of seeing believers who are hearers of "a" culture we would see positioned people, citizens of nation-states, negotiating knowledges in different ways.4*1 This approach, furthermore, requires a discussion of processes and relations that begins by asking how ideas and technologies travel.4 International projects of development and national projects of modern governance are both major channels through which publics on the periphery

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encounter science. Through a range of actions within identifiable institutions that make use of varied technoscientific projects such as epidemiology, immunology, molecular biology, reproductive sciences, sexology, and even public health planning, science comes to be unmoored from its historically situated origins to move as a truly translocal bundle of practices, meanings, and technologies. These processes of movement and localization occur through myriad institutional practices and ordinary activities. The mundane plans and routines through which the job gets done in international health programs contributes to the actual building up of worlds around certain understandings of bodies. In the case of HIV/AIDS, for instance, the current understanding of human-viralcellular interactions comes to make a difference first and foremost by becoming the basis for a wide range of continuing institutionalized actions. Latour has argued that the real-world efficacy of scientific discoveries—the effects that persuade us that something new and fundamentally true about the real physical world has been uncovered—are best explained not by assuming that entities or processes were "really out there" all along without our know ledge, but by truly appreciating the historicity of the intermingling of human and nonhumans. All scientific insights require upkeep, and those we regard as true accounts of the world are the ones around which the most stable, enduring, and extensive networks have been built. "What was an event," Latour (1999:168) says of scientific discovery, "must remain a continuing event." A growing body of work in science studies examines the public understanding of science and the controversies that erupt when members of the lay public monitor, evaluate, and challenge the accounts of scientists.48 What kind of authority does science gain, or loose, when it travels to peripheral publics via institutions of modern governance and practices of development? Do peripheral publics encounter certain facts as the blackest and most tightly sealed black boxes? Latour (1987) has used the concept of the black box to name the shift that occurs when the fluidity, contingency, and open-endedness of investigation ("science in the making") is stabilized to the point where its results becomes the unexamined given ("ready-made science") from which new research departs. For whom and under what circumstances are these black boxes sealed? Alongside critiques of geographical inequalities in the production of scientificresearch, it is worth considering the global distribution of resources for public participation in science-in-the-making.4>) It may seem odd that I apply the term technosciencc to AIDS education and its related discourse about sex. Clearly these arc not domains structured by science in the first order. Haraway, though, uses the term technoscience "to designate dense nodes of human and nonhuman actors that are brought into alliance by the material, social, and semiotic technologies through which what will count as nature and as matters of fact get constituted for—and by—many millions of people" (1997:50). "What will count as nature" is indeed what is at stake for Nepalis. and "what counts" (as well as who deckles and how) will indeed have effects both on bodies and on signifiers of identity. As I have here, Haraway explicitly aims to go beyond "a morality play about modern damnation

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or apocalyptic salvation" (1997:50). How, she asks, are people being interpellated by technoscience? Who turns their head when technoscience calls out "hey you!*'? This is a question we can pose to understand the science-public relation on the periphery. If we see the project of AIDS prevention itself, and the messages of AIDS awareness more particularly, as shouts of 'hey you!," who in Nepal hears the cry, who can interpret it, and who, then turns to find their "you" in its form? Notes Acknowledgments. The field research on which this article is based was made possible by a grant from the Joint Committee on South Asia of the Social Science Research Council and the American Council of Learned Societies, with funds provided by the National Endowment for the Humanities and the Ford Foundation. The Social Sciences and Humanities Research Council small grants program at Simon Fraser University supported background research on public representations of AIDS. I would like to thank Abana Onta for her invaluable research assistance and support, and the NGOs, planners, and AIDS workers in Nepal who shared their work with me. Dr. Rajendra Bhadra and Mrs. Renu Wagle wee especially helpful in patiently answering my linguistic questions and sharing so many of the insights and observations about translation that I attempt to convey here. Conversations about AIDS in Nepal with fellow researchers Kathy White and Linnet Pike, and with Dr. Paul Janssen, sharpened my understanding of the issues Vincanne Adams, Laura Ahearn, Don Brenneis. Leslie Butt, Dara Culhane. Kate Gilbert. Mark Nichter, and George Hadjipavlou. Hugh Raffles, as well as Dan Segal and an anonymous reviewer for Cultural Anthropology all provided useful suggestions, some—but not all of which—I have been able to incorporate into this article. 1. It does seems likely—given the presence of social factors associated with HIV transmission in Nepal, the background level of poor health and malnutrition in the population, and the scarcity of biomedical care—that many people have already died of what biomedicine would define as AIDS, without knowing their illness as such. The UNAIDSAVHO Epidemiological Update on Nepal reports rising HIV prevalence among sex workers in the Kathmandu Valley (from 0.9 percent in 1993 to 15 percent in 1998) and a very dramatic rise in prevalence among intravenous drug users (in 1997. 50 percent) (UNAIDSAVHO 2000). This information was not known among the AIDS workers who are the subject of this article at the time of my research. Readers should realize that this article reports the situation roughly from 1993-97. 2. Readers familiar with the numerous vociferous controversies surrounding AIDS science and public health strategies may find my claim of standardization surprising. Seen from the receiving end of this knowledge, however, and from the margins of its production, knowledge about AIDS and AIDS prevention does, however, come rather tightly packaged. The controversies are difficult to perceive and the common assumptions underlying various positions loom large. 3. See Farmer (1992) for a description of this relationship for Haiti. 4. This is, admittedly, a task that spills over the limits of this article, especially since I also throw international development, sexuality, and the politics ol AIDS into the mix. This article is part of a larger project in which ideas only signaled here will be further explored. 5. This is the starting assumption of Harding's (1994, 1998) attempt to bring what she calls "multicultural perspectives" to the question of the universality of science.

528 CULTURAL ANTHROPOLOGY despite her claims to blur boundaries. She advocates a pluralist view of comparable knowledge systems, but the "other cultures" in which these reside remain neatly separate and geographically fixed. See Cohen (1994), Farquhar (1994), and Kuriyama (1994) for criticisms of Harding's assumptions. Watson-Verran and Turnbull (1995) avoid the fetishization of "other cultures" by attending to what they call "assemblages" of heterogeneous practices and problematizing coherence in a way Harding does not. 6. As practice-oriented research in science studies demonstrates the heterogeneity among western scientific cultures, questions of commensurability, standardization, and coherence arise as a problem within mainstream science itself (Watson-Verran and Turnbull 1995:117, 127-131). For a discussion of the use of metaphors of bilingualism and pidgins in thinking about differing epistemologies, see Fuller (1996). 7. On the concept of language ideologies, see Gal 1989; Kroskrity 2000; Silverstein 1998, Woolard and Schiefflin 1994. 8. The research also involved a comprehensive review of media coverage on AIDS since the 1980s, collection of both educational materials (posters, pamphlets, videos) and "gray literature" from NGOs and donors, and reconstruction of the recent history of NGO involvement with AIDS intervention. The aim of the research was to follow the production of public knowledge about AIDS as this process was organized through the international development apparatus linking donors to NGOs. 9. This was reported by Picard (1996). The slogan became the prism through which were seen both the announcement of the promising new treatments with protease inhibitors and the critical commentary on the pervasive social inequalities underlying both vulnerability to HIV infection and access to new drugs. Delegates from underdeveloped countries of the South inflected the slogan with a question mark as they pointed to the huge disparity between the actual incidence of HIV infections (predominantly in their countries) and the preponderance of papers addressed to the narrow context of AIDS in North America, Europe, and Australia. 10. As Hacking (1999) notes, a constructivist claim is always an intervention that acts as a call to reconsider some taken-for-granted account of how things are. It is therefore a gesture that makes sense in a given context by moving against the grain of a cultural silence. 11. Like Hacking (1999), Latour (1999) intervenes in the debate that pits "reality" against "constructivism" by unwinding fundamental and long-standing philosophical answers to questions about truth, reality, nature, relativism, and language to show the premises that shape the terms of debate. Latour proposes that these seemingly intractable alternatives (either science identifies "real" features of the world "out there" or it is a form of social action) are based on notions of an inert, certain, objective, ahistorical "nature" that presents a clear unified face to the people who would know it. Instead, Latour (1999:15; 1987) proposes that what had been, under one kind of realism, regarded as inert "objects" in the world might be better thought of as an array of "nonhumans" that become "socialized through the laboratory" and enlisted and enrolled in various human projects. Latour argues that we must "retrace our steps, retaining both the history of humans' involvement in the making of scientific facts and the sciences' involvement in the making of human history" (1999:10). Although I cannot reproduce Latour's full argumfcnt here, his reformulation of notions of linguistic reference and relativism are pertinent to my discussion of communication about AIDS. Reference, Latour (1999) argues, is not a simple correspondence between words and the world, a single act of pointing. Rather, it is a series of practices that together can create "a quality of the chain of transformation, the viability of its

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circulation" (Latour 1999:310) or "our way of keeping something constant through a series of transformations" (1999:58). There is always a gap between form (or representation) and matter; it is the constancy and strength of a chain that allows us the valid sense that a scientist's account of a phenomenon refers back, reliably, to a stable set of relations that exist somewhere other than solely within the account itself. Latour makes these points in order to pinpoint the peculiar referential power of reductionism. Seeing reference as a chain of transformations also opens up a way of thinking about the relation between the scientific research on, say, HIV, and the further transformations those referential chains undergo as they are extended into public health policy and AIDS education modules and translated into Nepali. Following Latour, 1 see this not as a single leap from "accurate understanding" to "distorted misunderstanding" but as a series of moves, some of which strengthen the chain and some of which weaken it. Similarly, Latour argues for a concept of relativism and "relative existence" that replaces all-or-nothing claims with a definition of existence as a "gradient" that "allows for much finer differentiations" that can accommodate the tangled history of humannonhuman interactions, including the history of modern scientific efforts. Latour insists on relativism, but just as he rejects an absolutist dichotomy between belief and knowledge, so too does he object to conceiving of relativism as "the discussion of the incommensurability of viewpoints" (1999:310). Relativism should refer, according to Latour. "only to the mundane process by which relations are established between viewpoints through the mediation of instruments. Thus insisting on relativism does not weaken the connections between entities, but multiplies the paths that allow one to move from standpoint to standpoint." My discussion of AIDS and sex education here is a study of paths of movement. 12. Latour realizes that the politicization of the outer edges of what he sees as expanding technoscientific networks is important; hence his efforts to dismantle the belief/rationality dichotomy (1987:179—213; 1999) and his insistence on the way boundary-marking of this kind creates social "others." Latour's (1999) discussion of "relative existence" and the "spatio-temporal envelopes" in which entities exist, act. and are known suggests some important questions for anthropologists interested in addressing the actual relations among knowledge systems and actual politics of access and social justice. Latour himself does not pursue these possibilities, as his discussions tend to be located within the networks of technoscience he describes, rather than in the margins (for a discussion of marginality as a starting point for the analysis of networks, see Star 1991). In the discussion of Pasteur's microbes I mention here. Latour makes his argument by talking about how ideas become retroactively extended through time—he addresses a single (European) history but not coeval variation in space. 13. Other anthropologists conducting research on AIDS in the 1990s have noticed this lacuna in the scholarly literature on AIDS in nonwestern contexts and works addressing it are beginning to appear (for ethnographic examples, see Lyttleton 2000; Setel 1999; for a general discussion of this point, seeTreichler 1999:99-126). 14. These reasons might include: the explanatory and clinical power of the HIV hypothesis of AIDS; the investment in research efforts in this approach to AIDS; the dominance of the "AIDS knowledge" turf by molecular biologists, epidemiologists, and behavior-change oriented socia! scientists; the political use of reductionist thinking in shifting attention away form the social origins of disease. 15. Harding (1998) and Haraway (1997) take on this issue in different ways. 16. A distinction lhat is now giving way in Euro-American clinical practice to the term HIV disease as way of encompassing the continuum of health consequences of HI V

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infection. Nepali AIDS workers, however, are still struggling with the burdensome diagnostic definitions of ARC (AIDS Related Complex) and AIDS, enshrined in many of their source materials. 17. The actual number of people in Nepal infected with HI V is unknown, and data for estimating incidence and prevalence spotty. Statistics on AIDS in Nepal are better seen as social artifacts than empirical measures. The number 1 report here reflect the positive test results reported to or collected by the National Centre for AIDS and STD Control (NC ASC). This number is always presented as a crude count, and it is this count (rather than data on rates of incidence and prevalence) that is taken as a measure of the seriousness of the epidemic. In 1992, the number of HIV tests conducted by private physicians would have been very small, if there were any at all. It is now more common for HIV tests to be done privately, and it is widely felt that physicians or labs who do these tests are not reporting results to NCASC. The numbers recorded for more recent years are therefore more likely to under-represent the actual number of positive test results. For 1994, WHO estimated that there were 5,000 adult HIV infections in an adult population (ages 15-49) estimated at 9,863,000 (Mann and Tarantola 1996:495). The 1998 WHO was estimating that 26,000 people were living with HIV (UNAIDS 1998). For assessments of the HIV situation in Nepal in the early 1990s, see Bhattaetal. 1994 and Suvedietal. 1994. 18. A comprehensive picture of all AIDS-related activities and their level of funding is not obtainable because AIDS-related activities are often integrated into other, existing programs, donors are often secretive with their budget information, and funding is scattered across a complex field of government, international nongovernmental, and nongovernmental agencies that is impossible to track. Comparative data on other health expenditures is likewise unavailable, to my knowledge. Nepal reported receiving a total of$283,651 in 1996-97 to a UNAIDS study (UNAIDS 1999). 19. See Dixit (1990) and Rana (1991) for early projections about Nepal's vulnerability in the Nepali media. 20. Widespread rural poverty in Nepal has, for generations, driven massive labor migration both within Nepal and to other countries—mostly to India, but also to Southeast Asia and the Gulf states (Seddon et al. 1998). Male labor migration is associated with HIV transmission because mobile men engaging in sexual relations with different partners in different places create the sorts of sexual networks through which HIV can be transmitted. Concern about AIDS in Nepal, however, has focused much more on the other half of the equation: women in prostitution. In both public and official imagination a single story line about AIDS has prevailed: "Prostitutes" are the source of AIDS, men who "misbehave" sexually may pay the price, not only by contracting HIV themselves, but by infecting their "innocent" wives and children. Note that during this period, when sex workers and their clients were intensively targeted for interventions, the prevalence of HIV infection among intravenous drug users skyrocketed (see Note 1). Throughout the 1990s, only one NGO focused on harm reduction for intravenous drug users. Sexual transmission from sex workers was assumed in 1997 to be the main source of HI V infection in Nepal. 21. STD's have been associated with increased susceptibility to HIV infection, and as a health problem in their own right, follow the same routes of sexual transmission as HIV. Understandings of sexual behaviors, sexual networks, and the cultural values around sexuality are assumed to be useful not only for ascertaining where to target interventions but also for assessing the potential epidemic scope and (as more and more "risky" behaviors are uncovered) and designing awareness messages that would lead to

LANGUAGES OF SEX AND AIDS IN NEPAL 531 behavior change. Sex education is thought to be an essential tool for creating the sorts of understandings that would make people •aware" of AIDS and encourage them to alter their behaviors in order to a\oid infection. 22. It may seem obvious that AIDS interventions must deal with sex in these ways. and certainly at one level it is difficult to imagine an adequate AIDS intervention strategy that did not. The obviousness of this three-pronged approach, however, naturalizes many assumptions about what AIDS is. When AIDS gets framed, first and foremost, as a sexually transmitted disease, proposals for how to prevent the virus from finding its way into human bodies tend to focus on individual sexual behaviors rather than social relations (Hammar 1999). The best way to "frame" AIDS has always been debated: should it be understood as a medical problem, a development problem, or a human rights problem? (Fortrin 1989; Jbnsson and Sbderholm 1995; Seidel 1993). Each of these frames leads us to think about AIDS in terms of different proximate causes and different feasible solutions. In international AIDS work the medieal frame has encompassed certain aspects of the development and human rights discourse about AIDS. Hence in Nepal attention is focused on the sexual transmission of HI V and, to a lesser extent, the surrounding social "factors." 23. It also introduces sanctioned opportunities for voyeurism and. in the phrase of Linnet Pike, 'a soft-core public discourse" that opens "a moral space in both public health and the public sphere which is at once prurient yet safely anesthetized and sterile" (Pike 1999). 24. Patton (1990) articulates an alternative vision of AIDS education. 25. This approach created its own set of confusions, for the messages seemed to tell people that AIDS is a saruwa rog, a contagious disease, but at the same time to tell them that it does not sarnu (move from one person to another) in the ways other health messages tell them to worry about other diseases. These messages about AIDS came in the wake of other health education campaigns that did emphasize the role o\' mosquitoes (malaria), sharing cups (TB), and so on. in disease transmission. (My thanks to Ritu Priya for pointing this out). 26. The ethnographic assertions here are my distillations from my conversations with workers about language issues, my informal observations of their word choices in different contexts, and my socially acquired sense of the "feel" of words. Some workers were more reflective and articulate than others about these language issues. 27. In ethnographic research with development NGOs. the method of participantobservation requires collaboration with NGOs' efforts to design and evaluate programs and solve problems. My interest in language and communication converged with main workers' interests in producing clear messages and handling AIDS education. In collaboration with Dr. Rajendra Bhadra. 1 convened a group of about a half dozen experienced AIDS workers in a series of four-hour sessions to try to produce a Nepali "dictionary" of the technical and sexual vocabulary related to AIDS. We envisioned this dictionary as a resource for health workers, many of whom are themselves unsure of the meanings of the many English terms in which AIDS is explained. Our goal was to push to find the most colloquial, basic ways ot definingthe.se terms in Nepali. The final product was never published. 28. Nepali speakers distinguish between rog and betiiH. Rog specifically refers to a disease, however, and therefore not every bethn has a rog behind it. 29. Borrowing occurs when no other word is available to a speaker, the borrowed words, molded to the grammatical structures of the matrix language, are used as if they were words in the speaker's own language. Blom and Gumperz (1972) introduced the

532 CULTURAL ANTHROPOLOGY notion of metaphorical code-switching with observations about the ways a speaker's code choice can serve social functions. See Myers-Scotton (1997) for a review of sociolinguistic research on code switching. Code switching can be analyzed within the microdynamics of interactions (thus generating explanations of the factors that trigger a switch). Codes themselves have an indexical quality, and therefore a social meaning, as signals of identity, allegiance, and social position. Code switching can therefore also be analyzed within a wider frame that examines how code switching shapes and is shaped by wider social and political processes. 30. Silverstein and Urban (1996) turn to a view of processes of entextualization and contextualization. 31. Though I did not carry out rigorous sociolinguistic research these are basic observations. It should be noted that Nepal is a multilingual nation, and an analysis of this type should be done of practices between English, Nepali, and other languages. 32. Peer-education—the idea that AIDS information is most effectively presented by member's of a given social group—is one of the cornerstones of AIDS work worldwide (Williams 1996; for a criticism of the exportation of this model, see Murray and Robinson 1996). This model has fused with the system of "training trainers"—the idea that a body of expertise can built up in resource-poor settings by creating a network of nested training activities whereby the people who receive a week-long training can then go on to provide that training to the next group. 33. The training sessions reflect what is known as the syndromic approach to STDs, the approach currently promoted in Nepal. Health workers are taught to use a decision making tree to arrive at the appropriate drug therapy on the basis of reported symptoms. In training sessions, participants are taught to recognize certain things as symptoms of STDs, but not to differentiate among STDs. 34. In several training sessions I observed, this information threatened to overshadow AIDS as the focal information. In one, the middle-class women attending bombarded the nurse who was presenting this material with questions about contraception, infertility, hysterectomies, and other gynecological concerns. In others, some participants—many of whom were hearing about both diseases caused by germs and reproductive physiology for the first time—confused the "safe period" (the time in the menstrual cycle when fertilization is most unlikely) with the "window period" (the time between infection with HIV and the point when the test can detect it). The image of sperm fertilizing the egg tended to merge with the image of HIV attacking T-cells. I was struck, when I observed training workshops, both by the eagerness with which people sought information on the physiology of reproduction and the difficulties posed by the "experience-distant" inscrutability of the decontextualized biomedical presentation of this information in forms such as line drawings of the female reproductive system. 35. See Adams (1998) and Pigg (1995.1996) for further development of this point in relation to medicine. Silverstein (1998) makes it in relation to language, more broadly. Dirlik (1998) makes it in relation to globalization and social movements. 36. I came to appreciate this point when Dr. Bhadra commented that they found that when they taught health workers the actual names of various STDs and their causative pathogens, health workers tended to retain only this arcane information (and. he said, use it to show off) while forgetting the pragmatic training they received on syndromic treatment of STDs. 37. Given this. Clark (1997) has asked whether we can then posit sexuality as a "thing in itself to be analyzed in societies distant from this Euro-American history. Writing of the Hull of highland New Guinea, Clark argues that "clearly 'sexuality' as an

LANGUAGES OF SEX AND AIDS IN NEPAL 533

area of study imposes a Western framework of beliefs and analysis, which assumes that a category exists 'out there' but does not ask whether this is also a category for nonWestern peoples like the Huli." (1997:195). To the extent that the Huli could be said to have a concept of sexuality, Clark urges us to acknowledge "that sexuality is an undifferentiated experience for the Huli" and to consider "the moral dimension of sexuality and the way in which it is ontologically grounded in relations of power and gender." By defining sexuality as "a framework for interpreting experience based on notions of the body and related to sexual behaviors and attitudes" (1997:194), Clark insists that we not inadvertently inject Western concepts of sexuality into our theoretical frameworks (a point also made by Vance 1991). An analysis of sexuality in Nepal would therefore be a different undertaking from that of this article. 38. The problem of talking about sex splits AIDS awareness programs into two camps. On the one side, there are those who view this "difficulty" as inherent in "Nepali society" and therefore attempt to provide AIDS information with as little discussion of sex as possible. Nonsexual routes of HIV transmission are given elaborate attention, while sexual transmission is quickly glossed over with euphemisms. Blood receives a great deal of attention. In this camp are those who argue that every AIDS awareness poster should depict all routes of HIV transmission. On the other side, there are those who feel that "difficulty" is something that should and can be overcome. These are the advocates of sex education, of direct discussion, of raising uncomfortable subjects in the interests of public health. Both camps share a preoccupation with the nonfit between the discussion of sex that AIDS seems to require and the possibilities for producing that discussion in a Nepali context. AIDS workers always locate this problem "in our society." and although some workers feel Nepali society is much the better for not fostering what they view as "Western" attitudes toward sex, it is Nepal's inability to conform to the a model of what "talking about sex" should be like—rather than the nonfit of the model for Nepal—that they emphasize. 39. AIDS workers (and many other development outreach workers) tend to underestimate the ability of villagers to understand many words and concepts when they generalize about their work. At the extreme, they portray villagers as prone to confusion, especially by being overly literal in interpretations of what is said. In practice, most workers fail to gear their language sufficiently to local vocabulary and styles of explanation. The result is a paradoxical situation in which workers commonly theorize about what villagers won't understand (in a criticism of word choices, for instance) but in practice stick to the more difficult language. 40. These connotations can be, and probably are. occasionally overcome in actual practice. 1 simply wish to point out the tendency. Moreover, it is likely that over time understandings of AIDS will enter into popular consciousness, taking on new meanings, and freeing the very mention of AIDS from this strong link to the idiom of "awareness." 41. International Red Cross (n.d.) and CEDPA and SCF/US (1997) contain examples of this exercise as recommended exercises for training sessions. See Pike (1999) and Pigg (1999) for further comments on this exercise as it is used in Nepal. 42. My local AIDS NGO, AIDS Vancouver, uses it in orientations for volunteers as a technique for helping people reflect on "how open they are about sex." 43. One training manual inventively proposed to get-around this difficulty by providing trainers with stylized sketches taken from religious art, such as the struts of Kathmandu's many tantric temples. It was thought that these depictions of deutS (divine figures) engaged in exotic sexual acts might be more acceptable (CEDPA and SCF/US 1997). Trainers could then point rather than say.

534 CULTURAL ANTHROPOLOGY 44. When, in late July, 1997, it appeared that the Minister of Communications himself was on the verge of banning the show, the producers played only Nepali folk music as a signal to listeners that something was up. 45. These were conducted (with assistance from Abana Onta) on behalf of AIDSCAP as part of a midstream assessment of the show that 1 prepared under contract with Family Health International in the final weeks of my research stay. Interviewees were aware of my dual role as "consultant" and "researcher." The analysis presented here is my own and does not reflect the views or policies of Family Health International orAIDSCAP-Nepal. 46. Scott (1994) has usefully cautioned that we must not mistake our theoretical proposition that cultures might be more open-ended than previous theories had allowed for an assumption, in advance of any empirical evidence, that all cultures are actually equally open-ended. Boundedness may indeed be a feature of people's conceptual realities. I do not mean to rule that out here. 1 suggest, however, that it may be useful to start (both theoretically and empirically) at the points of interpenetration and feel our way toward those sites of boundedness rather than the other way around. When we begin ethnographically at the center of boundedness everything else can only look like boundaries dissolving. 47. Latour's (1987) criticism of diffusionist thinking is one starting point, but see Haraway (1997:33-39) for criticisms. 48. Although Latour assumed that the public only responds to a ready made science, we can point to many current controversies—from the antivaccination movement to alarm over genetically altered potatoes and boycotts of BGH milk—as evidence that some understanding of the "constructedness" of scientific knowledge has become part of public consciousness in places like the United States. One of the most striking examples, in fact, of the ways lay people involve themselves in science-in-the-making is that of AIDS activism (Epstein 1996). 49. AIDS is a case in point. While most HIV infections now occur in the developing world, basic research remains concentrated in the hands of U.S.-based researchers and a very small proportion of their work usefully addresses the problems of AIDS in resource-poor nations. Similarly, AIDS activism in industrialized countries has become a major site where lay experts have not only kept a close watch on the research process but have actively challenged its assumptions and intervened in its processes. Where AIDS activists in North America are well-informed about the controversies around various hypotheses and treatment protocols, AIDS workers in Nepal are handed an authoritative truth about AIDS and AIDS treatment. References Cited Abu-Lughod, Lila 1991 Writing against Culture. In Recapturing Anthropology: Working in the Present. Richard Fox, ed. Pp. 137-162. Santa Fe. NM: School of American Research Press. Adams, Vincanne 1998 Doctors for Democracy: Health Professionals in the Nepal Revolution. Cambridge: Cambridge University Press. Ahearn, Laura In press Invitations to Love: Literacy, Love Letters, and Social Change in Nepal. Ann Arbor: University of Michigan Press

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