Animal Yoga

As the summer comes to an end, I want to share a special part of my spiritual practice with all of you out there – millions, even billions of you – in search of inner peace and the wisdom of the zodiac or whichever comes first.

Just before I left for this summer in Nepal, I was at an end of season party with my soccer team in West Hartford and we got to talking about a new fad in Connecticut: goat yoga. This is a thing where you do yoga while baby goats run about jumping up on your back and snuggling your bum.

RIGHT????

That very weekend my friend Sam was planning to attend goat yoga, but I couldn’t go because, alas, I was headed instead to Nepal. But then, on the plane to Nepal, I got to thinking. Nepal lacks numerous amenities such as proper butter, a fully functional government, rural dental care, and Pandora. But goats are not a problem. So then I got to thinking more, and I what I thought was, let’s be open minded and work from a strengths perspective.

This proved to be fairly straightforward.  I started with a beginner practice:

Adorable Bunny Yoga.

The fan response was prompt:

 

I proceeded without hesitation.  I am a very focused person when I need to be.

Baby Chick yoga

 

French Bulldog At Sunset

 

Pairs Kitten Yoga

 

The Rooster

(this posture, which is excellent for improving the flexibility of the tongue to reach the tip of the nose, was immediately preceded by me trying to catch the rooster)

Preparation for Rooster Pose

 

A Herd Of Sheep Crossing a Road in Upper Mustang Yoga

Also, meditations on being very very still:

Farm Pose After Dental Camp

Pondering the impossible:

How is there a Dalmation in Nepal Pose

Ironic Yoga, very powerful in the Year of the Carrot:

I tire of you appropriating us in to your yoga names just because you’re humans withering stare dog

 

And finally,

Goat Yoga

Goats Doing People Yoga

                  

 

 

 

 

 

 

 

 

 

 

NAMASTE, HUMANS!!!

Our Health Care is Not a Playground

 

When I was at the Sindure dental clinic a few days ago, a 60-year-old woman I’ll call Mina arrived with three family members.  The family had walked an hour and a half from the next ward over because, after trying shamanism and home remedies for Mina’s dental pain, and they heard about Sindure’s dental clinic from neighbors.  All four of them wanted to be seen.

Sindure is our remotest clinic. The clinic assistant Biju has to walk about a quarter mile to fill a bucket of water at public tap for use inside the clinic. When our technician Jagat examined Mina, he found that she needed two teeth extracted but also that she had low blood pressure. A discussion ensued: given Mina’s age, medical history, and low blood pressure, should Jagat perform the extraction? Our office staff had taken a five-hour bumpy private jeep ride to get to Sindure. In the monsoon, it would take this family the better part of a day on public transportation to reach a hospital, where, possibly, the dentist would or wouldn’t be in.  They might or might not be able to return home the same day. The hospital might or might not perform an extraction on a patient with low blood pressure.  In the best case scenario, the cost of transporting the whole family, paying for treatment, and maybe overnighting in the city would be significant.

In the end, Jagat treated Mina with silver diamine fluoride, a noninvasive carries-arrest technique that turns decay black and hard, safely slowing and often halting the disease.  He advised her to return the following week, and if her blood pressure looked better then, he would extract the two teeth. The treatment cost her sixty cents. In all except one or two of Nepal’s hospitals, silver diamine fluoride is not in practice, although in the U.S. it has now been approved by the F.D.A.

Later, we posted the case to our private JOHC clinical page, where all of the rural technicians can discuss case questions with Dr. Bethy and Dr. Keri. What blood pressure is too low?  Does the patient’s age matter?  How do we factor that realistically Mina is extremely unlikely to seek urban care even if we refer her?  What role does patient counseling play?  What other things determine whether such a patient can safely have an extraction done in a rural dental clinic, and how do we progressively bring different levels of care together over time?

What about the grandchild who was with Mina, probably not more than eight, whose access to a hospital is burdensome enough that it only makes sense to go there for emergencies, not simple procedures like silver diamine fluoride or glass ionomer fillings? Why should an eight-year old have to let a disease progress until it’s an expensive emergency in order to be worth caring for, when early intervention can be made accessible?

Mina’s situation is an excellent example of why we are trying to get the national health care system in Nepal to adopt primary dental care in rural health posts and school brushing programs in the education system. It seems kind of obvious, but in fact our approach is very uncommon, even outside of oral health (where there is literally nobody working on a systemic innovation in Nepal).  The majority of rural public health programs we see either focus on a single, one-off hospital with unique resources, or try to please donors by scaling up over whole districts at the expense of rigorously exploring single instances of a model.  By contrast, we’ve added a few rural dental clinics each year and iteratively improved the design and process of creating-community based oral health care. Now we have a strong if imperfect proof of concept to present to policy makers. We think that what we’ve done in eight places like Sindure could be done in all 3500 of Nepal’s health posts, bringing sustainable primary dental care to about 20 million people.

Anita working at her clinic in Katuwachaupari, Parbat

It was last summer in 2016 that we first presented this model to national level policymakers, and our slides immediately struck a hot wire.  The reason is that, although you never knew it, dentistry is an amazingly political topic. This is true even in the U.S., where there’s been a movement to create dental therapists who can provide a limited scope of practice in remote and underserved areas where doctors with $600,000 in student loans will never set up clinics. But who poses the most forceful opposition to dental therapists? Dentists.

Dentists are not the only professionals to oppose what is perceived as the degradation of their trade by mid-level providers with less training, but they are particularly energetic about their turf.  I recently read a Washington Post article that compared the dental lobby in the United States to the gun lobby.  The disagreement is framed as protecting the poor from low-quality treatment, but in practice, the position protects the wealthy from competing investment in effective treatments that could reach people without the ability to pay.  There are a good number of such treatments that have been well-studied and do not require pricey providers with PhDs to administer them.

In dentistry the problem is made even worse by the discipline’s roots as a cosmetic discipline.  Dentists used to be barbers!  Even now, the field is separated from the rest of medicine, with dental students educated outside of medical school. If you’re American, dental insurance is probably an appendage on your main health coverage. Even though medical science has long since understood the importance of oral health in overall health, dentistry remains siloed in its own world with its own rules. Therefore, it is also elitist – yes, I said elitist – because as “bonus” medicine, only those who can afford it get it.

The road back from Sindure…not so easy, even in our jeep!

We’re facing the same situation in Nepal, but the ratios are vastly different. Here, about 80% of the population lacks access to oral health care, and oral disease is one of the most widespread health problems in the country. Dental clinics are exclusively in urban areas, and mostly in the capital, but the majority of the public is dispersed across remote hills. With bazillions of dollars going in to nutrition, maternal health programs, cardiac care and diabetes, all of which are directly related to oral disease, there are almost zero dollars being spent on oral health care…because, even in the year 2017, it is still widely viewed as a cosmetic issue.

Like American dental therapists, our dental technicians provide appropriate, high quality basic dental care in rural areas, but in Nepal that’s almost everywhere.  They also refer to secondary level care, providing an access pathway for people like Mina who, without at least getting a local referral first, would be extremely unlikely to take herself to an urban center for dental medicine.  But when we go to policy makers to promote this model, the dental lobby counters with concerns that dental technicians are poorly trained and won’t stay within their scope of practice.  Which is a real concern when there is no regulation, but is not what our evaluation last winter showed when technicians practice within the structure we’ve created.

Yesterday, Aug 2017, was our second central level advocacy meeting.  This year we were joined by two of our dental technicians, K.P. and Anita, who both work in clinics that received local government funding this year.  They’ve treated thousands of people in their villages.  We were prepared for some heated debate…recently, the Nepal Dental Association shut down a government training in the Basic Package of Oral Care that provides the basis for the work our technicians do.  The topic is currently so frantic that nobody from the government attended our advocacy workshop! So it was just us, some open-minded dental professionals and social workers, and a very strongly opposed contingent of the NDA.

The first two hours of the workshop were very polite.  K.P. and Anita each spoke about their experiences – for example, Anita’s clinic runs on Mondays, and she told a story of an elderly man calling her on a Tuesday asking how he’d make it a week. So she knowledgably instructed him to pick up two medications at the Health Post, and the following Monday extracted the tooth to his great relief.

The push back started cordially, and then came a torrent. “Little knowledge is a dangerous thing,” one young dentist pointed out, telling a story of a minimally-trained provider he had once observed performing a procedure incorrectly. The discussion period morphed into a rapid-fire series of dissenting speeches framed as questions:

How are these “technicians” selected?

You say they get two years of training and supervision. What is this training? What is this supervision? 

You know they will only work for your organization for a while, and then they will leave and go open illegal dental practices. 

Why do you call them technicians? Technicians are people who fix chairs.

One time, I saw a patient with an extracted tooth who turned out to have cancer. What if it’s cancer?

You say the dentists won’t go to rural areas.  I have been to Ruswa, and Dhading, and Humla!  We have all been!  Who are you to say we will not go to rural areas?

Dental students all do internships. We can staff rural dental clinics with interns on temporary rotations.

You’ve spent all this money over the years. Why didn’t you put that money in to setting up one proper referral center with equipment? The dentists will come to it, if you place the setup there. 

Extraction is an invasive technique requiring anesthetic and primary care does not include invasive techniques.  These unqualified imitators are practicing secondary level care.

Somewhere in this deluge of critical questions a most interesting declaration fell out of the sky:

Our health care system is not a playground!

This criticism was aimed at our technicians, and these are all objections we’ve heard before, and we expected them. They frame a convenient, self-referencing argument:

The exclusion of poor people from health care is for their own protection from under-trained hacks.

I was given “three minutes” to respond to a barrage of about forty questions.  Mina crossed my mind, and all I could think of was, our health care system is not a playground.

Indeed.  While we are all here navel gazing, real people are needlessly suffering.  There is a big difference between visiting a place for a day, I pointed out, and sleeping next to someone suffering from pain and fever with an infection, a day’s bus ride from the nearest badly-regulated public hospital that may or may not have a doctor who can treat the problem.

What about the use of resources to build sustainable providers instead of randomly placed dental clinics for imaginary doctors to flock to?  If only there weren’t so many rusting supplies sitting in rural places, waiting for people to come use them.  If only the professional medical lobby put the same effort in to supporting, monitoring, regulating and creating referral systems with community-level providers as it is putting in to obstructing them.  Just think what we could have achieved by now.

Our health care system is not a playground.

Here’s the thing.  Nobody wants your interns, your mission camps, your adventure dental care trekking, your once-a-month community service, your charity. We want dignity. We want providers who are appropriately trained for their settings, who know their communities, who will answer phone calls on Tuesdays, who are there for the long haul and not as a resume builder on their way to something better. We want specialists and we want them in the entire country, for everybody, not in the one community where self-congratulating people established a referral center that, happily, expands their own reach. We want something that can actually be implemented, afforded by the government, where there will be a willing workforce, something that is sustainable.

Our health care system is not a playground.

No, it’s not.  Little knowledge is a dangerous thing.  Somebody answer to Mina.

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The JOHC mob-squad on the way to a central level advocacy meeting. Program Director Aamod Shrestha; technicians K.P. Acharya and Anita Subedi; Medical Coordination Officer Rajendra Sapkota.

 

 

Another Room in Heaven

For someone who has spent 15 years in Nepal, I’ve travelled very little in the country, choosing instead to burrow further and further in to a single community, a single home, a place where now twelve year olds have always thought of me as a part of their world. It was only a few years ago that I suddenly thought: I’d like to explore. I’ve started stetting aside a few days every few years to go climb out on a spine of rock some place, in some location that percolates on a back burner in my mind until it bubbles over and asserts itself: this is the time, go here.  Then life adapts around it.

The Way to Muktinath

One way to travel is to go to see things that are new and unfamiliar and exciting or challenging – like that time I went to Murad Khane in Afghanistan, or when I floated in the Dead Sea, or the month I spent in New Orleans doing oral histories for StoryCorps after Hurricane Katrina.  But this is something else, a magnetic pull to a place that is already inside me, a dot on a primal map created a long time ago.  In 2013, Prem and I went to Mardi Himal by a little-traveled route comprised largely of goat trails snaking along a blade of snowy ridge that rims a basin of Annapurna giants. It was winter, everything wide and blinding, the sunrise spilling pomegranates and mandarins and pineapple juice all over the jaws of the cold earth. When I got there, it made sense.

Now it is summer. Muktinath sits north of Pokhara between Lower and Upper Mustang, a stone’s throw from the Tibetan border, and houses a famous complex of Buddhist and Hindu temples. For some time now I’ve been pulled north, toward the areas of Nepal influenced by Tibetan culture, and also where the landscape climbs up and stays high, where the trees fall away and leave a desert mountainscape that stretches off to the Tibetan plateau, a mystery, an uncrossable border. In the winter even local residents often come down from Mustang to the valley to escape the unforgiving snow and cold.

Prem Bhinaju and I met a bus by a curb in Lakeside early on Friday morning. It was headed to Jomsom, which is only a 15 minute flight from Pokhara, but unlike crystalline winter, the summer is dense and foggy and flights have not come or gone from Jomsom in a week. That leaves us with what should be a ten hour bus ride. You know where this is going.

There’s the obligatory 2.5 hour delay when a bearing that has to do with steering left needs fixing, and magically, the Bagloon Highway presents an auto shop strewn with hulking shells of buses and tractors and cars and unidentifiable transport components, so we pull over to fix the bearing. We set off again around noon under ten-ton heat, but I am relieved to be on the move with my day pack and with Prem, my most familiar travel companion. The road winds upward and the Kali Gandaki River drops below us, black and rumbling with coal-colored silt that will settle by the time the torrent gets to in Pokhara, where it is called the Seti Gandaki, or White River. The road becomes a road story that I can’t tell because my mom reads this blog, but even passengers local to Jomsom are praying and squeezing their eyes shut while we loll side to side on a road that, from afar, looks like a child dragged a pencil across triangles of high mountain forest and then got distracted with a sandwich. In the end, aside from knuckles white from clinging to the seat in front of me as if that can save me from a long descent in to the Kali Gandaki – one of the deepest gorges in the world – I come out fine. Prem and I arrive in Jomsom at 7:30pm.

I know I’m in Nepal, but Jomsom looks like a ski town and I have to keep reminding myself that this is Mustang. We clomp along a stone-laid main street with quaint local shops and hills rising up behind them. In the U.S. we’d call the hills mountains, but in Nepal, the mountains are the sheared white rocks twice as tall that are currently lost in monsoon cotton one row further back on the horizon.  It is hard to believe anything could tower over the already looming hills – I remember thinking the same thing at Ground Zero, knowing that Lower Manhattan’s massive skyscrapers had been dwarfed by the Twin Towers.  It is impossible to imagine land up in the middle of the sky, but I know Diligiri is there, behind the clouds, a thousand stories high.  We settle in at a hotel.  Local plum wine.

Our walk to Muktinath starts the next morning and takes two days, one long day up and one long day back. We walk along the Kali Gandaki in a landscape created contradictorily by the upward smashing of tectonic plates and the downward gouging of receding glaciers. The result is a desolate, heaving geometry, eons of history piled atop one another and laid bare straight from river to the sky. Dwellings impossibly carved out by people who once migrated southward from Tibet are clustered in the sweeping rock face, and the occasional modern village is a patch of irrigated greenery in a borderless expanse of brown. This should be the province of giants, but we are just tiny people, our feet sliding over bazillions of even tinier rocks, where fossils casually present themselves because nobody has owned them yet. They were once underwater and they have been here forever and ever and ever.

The climb starts. No houses, no villages, no ancient dwellings for hours. Prem Bhinaju finds a fossilized creature with gold flecks in it. Uncharacteristically , I haven’t exercised in weeks and my legs feel like playdough, but it’s cool. I have an actual fossil in my pocket.

We arrive in Muktinath around five, eat something, and rest for a while. Then, because tomorrow will be a long day and we’ll be pressed for time, we go out to explore the area around the outside of temple complex.  That will leave us time to go to the temple itself in the morning.  I leave most of my things behind except for my SLR camera and rain jacket. Now that it’s evening a slight mist is drifting downwards, uncommitted to getting us fully wet. Dusk turns dreamlike and enchanted.

Prem says we’ll walk up to the place where the path to Thorong-La pass starts. We would need a whole extra day to get to the 5,416m pass, but there is time, at least, to lay eyes on its direction. We circle the wall of the temple complex, and two nuns are just leaving, one wearing hot pink sneakers. I ask if the nuns if they were born here in Muktinath and they say yes, and even though that is a completely unremarkable fact, to me it seems incredible because I am so far away from the world I know. They bustle off to the nunnery.

We climb quietly past parts of the complex wall that have cracked and broken in the earthquake two years ago, and emerge in a widening field that slopes upward and disappears in to a fog. “The way to Thorong-La,” Prem says. He says we are at 2800m. I say, obviously, we should walk up another 200m, so even though evening is turning denser, up we go in to the haze.

Some ways ahead, a walking bridge is slung across the gorge to our left and we climb until we reach the concrete block anchoring the bridge to the ground on our side of the river. Without any comment, Prem sits and I follow, and then I lie back and stare in to the unremitting white sky. No variations in density or color, no dragons or bears or wizard faces, just an endless, depthless white.   Further up the green rocky slope, on the other side of the embankment of fog, is the path to Thorong-La; below us is everything we’ve come from.

Quiet.  I am filled with a profound gratitude for Prem’s company, his silence, the easy way we can walk up to this concrete block and sit on it at dusk and do nothing at all.

After fifteen minutes, I decide to cross the bridge, for much the same reason we walked up 200 meters. We’re on one side of a bridge, so it should be crossed.  The first step out over the edge ofthe gorge sends a thrill through my nerves, and then out I plod out over the wires, which undulate a little with my steps, until I am standing directly over the water gushing down from the high mountains.  A thunderous cloud of sound rises up through my bones and engulfs my senses; I can barely hear my own breath. It feels like the river is running right through me, and when I shout or chant the water picks up the sound and rumbles away with it taking my voice down down down down to all the places we were.

The instant I step back on to the concrete block the mountain silence envelopes me again; magically, the roar of all that water is audible only between the walls of the gorge. Prem takes a turn on the suspension bridge, and then we head back down the green slope and circle around the other side of the giant temple complex.  Night is creeping in slowly, as if stalling a little to give us just enough time to see one more wonderful thing.

We come to an area of the hill I have been viewing from below in the mist: rows and rows and rows and rows of prayer flags strung behind small white structures scattered high up on a hill. I studied Tibetan Buddhist funerary rituals for a course I took this year, and throughout the evening, my sights have been trained here. When we passed the nun in the hot pink shoes, I pointed this way and asked if it was okay to pay a visit. She said yes. Prem and I make our way over the hill toward the fluttering prayer flags.  He walks down toward the road, and with barely a word, I go up.

I’m expecting to see signs of sky burial, but I realize quickly that this is a land burial site. Everything feels unified and still, but also light and high. There are small cairns everywhere, placed for passed spirits to find refuge to heaven, and as I walk between the grave sites, it suddenly occurs to me to ask Prem, still at an audible distance, if he thinks I could build a cairn. Why not, he says, and sits down on a rock facing out over the endless prehistoric topography while I climb higher up and find a patch of ground abutting the faded squares of color calling tut-tut-tut as the wind tugs them from their strings.

Prem never asks why. He just waits.  And when I have built it, a stack of stones among all the stones and fossils, another room in heaven, and when I have sat over it and cried for some minutes, I walk down the hill and we leave.

Night falls at last.

 

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