Ice cream cone practice

If the Guiness Book of Records took entries for Aamaas who had rarely left their villages in Nepal and had the most friends living in the U.S., our Aamaa would win by a landslide. I don’t even know how many people have been to Kaskikot to eat in Aamaa’s kitchen in the last decade and a half, but it’s an impressive cohort of my friends and family, even if you don’t count all the tourists that Prem bhinaju brings by. We wanted Aamaa to get to see as many of them as possible here in their natural habitat. I put out a call for visitors.

My friend Jackie drove all the way down from Maine to meet Aamaa in Connecticut. We went to a hot air balloon festival and ate ice cream.

“We should go. It will be dark soon,” Aamaa clucked.

“The whole point is to see the balloons lit up in the dark!” Bishnu and I objected.

“It’s night,” Aamaa countered logically. The fact that everyone isn’t basically inside by dark is one of the features of American life that Aamaa seems to find continually alarming. As a side note, she has been busting my chops for being out after dark in Kaski for fifteen years.

We had dinner (after dark) with my friends Heather and Abigail and their son Teddy. Heather was in Nepal with a group of my friends in 2010 for a big hiking trip. I took Aamaa to my IMT clinic, where she was received like a celebrity by all of the therapists. Of course, Aamaa knows all about IMT because in 2013 we did a major manual therapy project in Kaskikot based on the model we use in our oral health program, and three of my IMT therapist friends spent a few weeks in Nepal.

For the weekend, we went shopping in a grocery store (what?), got our nails done, did our hair, cooked an insane amount of Nepali food, and had an all day Aamaa-Rama party. Will, Lissa and Catherine, the therapists who’d come for the IMT project in 2013, came in from Boston and D.C. Dr. Keri, my cousins Robert and Audrey, and my friends Mona and Todd all made long drives to meet Aamaa. I set up a slideshow to play through photos and we sat around all afternoon seeing friends.

The next morning, Bishnu and Aamaa packed their things to drive down to D.C. to stay with Bishnu and my parents.  Will and Lissa came over for breakfast, and then we put everything in Catherine’s Mini Coop and I stood on the sidewalk.  Aamaa got in the car an buckled her own seatbelt.

At last, it came…that withdrawing feeling that I am used to having in the front yard of our gentle orange house in Kaski. Like a fishnet has been tied around my insides and is being pulled away by the force of a world that cannot come with me.  The thing is that usually I am on the other side of it, moving away from an anchor and feeling that world slip away as I leave.

This morning, I was the one standing on the porch, watching the color and sound move out in to the road.

“This is no fun,” I mumbled.  I would be going down to Maryland down to my family in a week.  But suddenly it felt like I couldn’t remember the last time I’d been alone.

“No kidding,” said Aamaa in her matter of fact, unsentimental way.  “That’s what I do.  Everyone leaves and it’s not fun and I sit and cry.”  And it’s true.  Every time a group of us come to Kaski, we leave.

“Nice job with the seatbelt,” I noted.  “See you guys next week.”

They pulled off in Catherine’s car, and I waved, like Aamaa always does, and went back in to my house to think of something to do.




All These Lights


It’s true that the hardest part is undocking from the house in Kaski, but after that, each step further away gets less difficult and more strange. Now we are completely ummoored and nothing makes sense at all: Aamaa is in JFK airport.

Bishnu was waiting for us and she and Aamaa were reunited after four years. It was quite undramatic.  My parents, by contrast, have been known to stand in the waiting area with an enormous welcome home sign and my mother has a happy attack that involves all four of her limbs. Nepalis are much more subdued. But Bishnu was wearing an orange shirt, a gesture she planned after seeing the photo I posted of Aamaa and me leaving Kathmandu.  Bishnu had also ridden a bus all night from DC, and given that Aamaa and I had been traveling for a few days and endured airport dinosaurs and nauseous teddy bears, it appears I was the only one who was really enthusiastic about taking arrival this picture.

We got in a car back to Connecticut and showed Aamaa how to buckle her seatbelt. The car set out and was soon rising over the Whitestone bridge, where Aamaa caught her first glimpse of the edge of the ocean.  It occured to me then that I hadn’t thought to point the ocean out for the fourteen hours we were crossing the Atlantic. Aamaa looked out the car windows from side to side. “All of this is America!” she exclaimed.

A few weeks ago, my wallet was stolen in Cambodia with my passport, credit cards, all of my IDs, Verizon sim card, and house key. So when we pulled up to my house, I had no keys, no phone, and as it turns out, my internet had been turned off because the automatic payment on the cancelled credit card was rejected. We had to solve at least one of these problems, so we went to the mall. Que the following: Aamaa has only been in the U.S. for about seven hours and we’re in the Apple Store.

At one point I left to go to Verizon to get my lost sim card replaced, and when I came back, Bishnu and Aamaa were sitting outside Nordstrom’s, facing away from me and looking small in the wide, polished corridor of the mall. It is going to take me a while, I thought in a jet-lagged daze, to integrate the incredibly odd experience of seeing Aamaa in these spaces.  In the next few days she would be cooking in my kitchen, strolling down the Farmington Avenue sidewalk in West Hartford, pulling open the door to Starbucks, sitting on a treatment table at the IMT clinic where I worked. Imagine if Barack Obama was suddenly sitting in your living room, watching the TV he is supposed to be inside of. Or if there was a zebra standing in the Emergency Room. Or orange juice coming out of the kitchen sink faucet. The components are all fine, they are just extremely jarring in the new arrangement.

After it is dark, we are driving up Farmington Avenue. Aamaa has buckled herself in to the front seat and Bishnu is in back. We pass a synagogue.

“Aamaa, that’s the temple where people who practice Jewish religion go to pray,” I say.

“What’s Jewish religion?”

“I’m Jewish!”

“Oh right,” Aamaa says.

In the next block, we pass a church.  I point again.

“This is where people who practice Christian religion go to pray.”

Aamaa peers out the window. “We’re Christian, right?”

Bishnu lets out a torrent of giggles. “Aamaa, we’re Hindu!”

“Oh,” she says. By American standards, Aamaa is fairly religious. She mostly sticks to a Brahmin diet, lights incense and prays many days of the week, observes the dictates of the lunar calendar and the demands of solar eclipses.  She honors her ancestors and has practiced ritual widowhood since the age of twenty-two (although you could argue that that’s more about the patriarchy than religion). But from her point of view, Bishnu and I reflected later, it’s just dharma. She’s never had to label it.

Another block of Farmington Avenue rolls past, and we stop at an intersection.

“What’s with all these lights hanging everywhere?”

“They’re traffic lights,” Bishnu says from the back seat. “They tell the cars when to stop and go.”

“Ah, they put them out at night,” Aamaa concludes.

Bishnu and I start giggling again. “No, they are there all the time for the cars,” Bishnu corrects, and explains how the traffic lights work.

Oooooooh,” Aamaa replies.  And then, for the rest of the week, each time we pull up to a traffic light, Aamaa will begin narrating. “It’s red Laura, it’s red, stop….Ok, it’s green now. Go. Go go.”   This is one of the things that I will begin to quickly see about Aamaa: how efficiently she absorbs ordering details of this completely new world, and then references them constantly with an air of mastery and satisfaction. This process of discovery and wonder is absolutely magical to witness. I soon realize that being with Aamaa is a lot like being with my nephew Jonah was when he was about four, and we think that children outgrow their ability to be enthralled by traffic lights because they get smarter. Actually, children just get used to the way the world works. In point of fact, a traffic light is a pretty thing up in the air that brings discipline to the otherwise entirely chaotic phenomenon of traffic (see: Nepal, roads). To splash around in the delight of traffic lights with a highly competent sixty year old adult is a beautiful experience.

We make our first Nepali dinner together and sit at my kitchen table to eat with our hands. In Kaski, Aamaa has usually just boiled milk fresh from the buffalo, and from her throne on a pirka by the side of the fire, she gives us each a cup of velvety, hot cream with dinner.  Now we are taking care of her, and Bishnu pours Aamaa a cup of organic whole milk from the grocery store.

“Aamaa, have some milk.”


“…Did you try it?”

“Not yet.”

“…Try the milk.”

“I tried it. It’s bad,” Aamaa declares without pause.  On either side of the table, Bishnu and I immediately collapse in hysterics.

On our second night, Bishnu has to leave at four in the morning to fly to Virginia for an interview. A short while later, Aamaa comes knocking on my bedroom door, which shares a corner with the door to my kitchen.  I get out of bed.

“Laura! What is that noise?”

“What noise?”


“The refrigerator?”

“Oh, okay. I was scared.”

“It’s just the refrigerator,” I reassure her groggily. We go back to sleep.

At 9:00, Aamaa raps on my door again.

“Laura, get up,” she says. “I’ve been up for hours. I thought I’d make some tea, but I don’t know how to use that stove of yours. And I can’t even go outside because I don’t know how to open the door.”

“The door?” I reply, confused. Maybe the deadbolt is locked? And then I realize Aamaa has probably never used a rotating doorknob before. “Oh. I’ll show you how to open the door,” I say apologetically.  For the rest of the week, each morning that I wake up, Aamaa is sitting on the front porch, observing neighbors walking by.

“I learned how to say, ‘good morning,’” she reports.


The Other Skies


The first thing I have to do is convince Aamaa to wear one of her new kurta salwaars. She has spent 60 years wearing a more dignified sari and she’s shy to dress like a girl. I insist she will be a lot more comfortable on our 24 hour journey with trousers on.

Bhinaju and our cousin Laxu come to the airport with us. As we stand outside the door to the airport, again there seems to be a strange inversion of everything. We say goodbye and move in to the 24-hour netherworld of air travel, but the moment when I detach like a raft in to the sea, alone and timeless until landing back in the rest of my life, never comes. Instead, all my focus is on Aamaa while we pass through various inexplicable passages and security checks, making goodbye phone calls along the way.

We end up seated with Chandrakala, a charming woman probably in her mid-forties leaving Nepal for the first time to go be a maid in Greece. I explain everything from the seatbelt to how to order drinks and use the bathroom. I set up their personal TVs with films for them to watch. They both look disapprovingly at the glass of wine I ask for, so I make a point of asking each of them repeatedly if they would like some wine during the flight. Aamaa has a million questions. Is it night or day? Can I put my passport away yet? Are mom and dad awake now? I don’t know. I’m used to not thinking about any of these things.

We spend the flight talking with Chandrakala didi and when we get off the plane in Doha in the middle of the night, the three of us stick together. The Doha airport will be the first thing we encounter that is a developed country version of the comparable thing in Nepal; Tribhuvan International Airport in Kathmandu only supplemented its two small departure terminals a few years ago and the waiting area is decorated with rows of cheap, attached metal chairs that can be dragged about in units of three. The Doha airport is a dazzling maze of high ceilings, moving walkways, shiny things, monitors, duty free shops where beautiful women are illuminated by fluorescent lights, and of course, the enormous random nauseous teddy bear that is taking up space at the center because space needs to be taken up. It occurs to me how strange it is that in modern times, the first thing an immigrant from a developing country will see in a wealthy country is an airport, which is one of the weirdest environments modernity has to offer.  For example, Aamaa couldn’t even think of a question about the following dinosaur under a passageway in the airport:

I lead Aamaa and Chandrakala didi to the sleeping room and we all try unsuccessfully to doze off. Aamaa and I both end up stretched out on the floor instead of the awkward lounge chairs, and I appreciate how we must look, sprawled out on the ground in a room full of disciplined travelers using the chairs.

We go to the bathroom and use an automatic hand dryer.

By now we are all aware that we’re going to have to abandon Chandrakala didi to the Doha airport when our flight leaves for New York. I take us out to the nauseous teddy bear where a bank of monitors will show Chandrakala’s departure gate when the time gets closer, and explain to her three or four times how she’ll navigate the list of English symbols. Chandrakala didi is literate but uncomfortable with English, and if you don’t know what a gate is or how an airport works, reading the monitors is just one obstacle (how do you even know you’re supposed to read a monitor?). There are many Nepalis working in the Doha airport and we chat some of them.  Chandrakala didi will be able to ask someone if she needs help, but it still feels wrong to leave her alone in the glowing Doha airport with its mysterious halls and signs and statues. Eventually we have to say goodbye, and she sits outside our gate watching us go.

Every time Aamaa and I have to pass through a checkpoint or security screen, the international airport staff first assume that we aren’t traveling together, and then want to know what in the world is going on. Aamaa has all the looks of a first-time traveler from a traditional part of Nepal, and in addition to the fact that I have all the looks of a private-school educated white suburban yuppie from Connecticut, I tower over Aamaa by about eight inches.  Since she doesn’t speak English, I usually have to translate instructions.  After figuring out that we go together, most people assume I am her daughter in law, which would explain how I know Nepali and why I’m the one shepherding her on an overseas journey. “This is my daughter!” Aamaa giggles as she corrects enthralled security guards and airline attendants. We make our way from counter to counter and checkpoint to checkpoint, crossing the globe in a little bubble of delight that we make no sense.

Finally we board our fourteen-hour flight to JFK. We get incredibly lucky with an empty middle seat on a mostly full flight, so we’re able to take turns properly sleeping. I was worried about how Aamaa would handle strange food made by unknown people, but she mostly exclaimed over amount of it, approaching each tray with curiosity and then asking me if I wanted to eat her pats of butter because she was full from the continuous flow of food.

“That goes on the roti Aamaa, you don’t eat it by itself. It’s like ghee.”

And then the next tray would come and she’d ask me if I wanted the butter again.

We peered out the window at the rolling white puffs lolling off to infinity and Aamaa asked if the clouds were the ground or the sky.

“The sky,” I said.

“Does this plane also go to the other skies?” Aamaa asks, long after we’ve lost track of night and day.

“Other skies?”

“They say there is this sky, and then a sky above this, and then a sky below this one,” Aamaa says. “I don’t really know much about it. But I was wondering if this plane goes to the other skies.”

I gaze at her.

“I don’t really know,” I say. “I don’t know much about it either.”

Many trays and questions and naps and pats of butter later, we break through this sky and New York comes in to view. Aamaa reaches behind her for my hand as she stares out the window, and with a dramatic rumble, the plane sets us down on the ground.


First Firsts


The morning we were leaving, Aamaa’s brother and mother come over and we ate together. Aidan and Pascal were looking unacceptably dapper in their school ties. I can barely stand it when they look like this and it shouldn’t be allowed on these mornings when I’m leaving the country and won’t get to see them for five or six months.

Didi accompanied Aamaa and me to the airport, and while we were waiting for the flight to arrive, we made our first stop in a public bathroom. I showed Aamaa how to use the faucet at the sink (actually, the entire bathroom is a mystery), and what I hadn’t realized yet was how many different kinds of faucets there are between Pokhara and Hartford. Finally it was time to say goodbye to Didi.  We went through security, and now it was just us, on the road.

We climbed in to a small commuter plane for Aamaa’s first airplane ride.

Aamaa had only been to Kathmandu once before, when she picked up her visa a few months ago. We arrived at my friend Aparna’s house and Aamaa said wanted to accompany me to my meetings. I was afraid she’ll be bored.  Why should she sit around, she wanted to know, while I go do things in Kathmandu?  Let’s see the city!  Let’s see what I do when I’m here, doing all these meetings, she said.

My first meeting was with a Berkeley professor in a coffee shop. I ordered Aamaa a salad.  She poked at it suspiciously.

“Uncooked spinach,” she pointed out.

“It’s a salad,” I offered.

“Raw leaves,” she sighed, and switched over to helping me with my French fries instead.

My second meeting was on a fancy rooftop restaurant in a mall. On the way there, in the cab, Aamaa craned her neck at the window. “These buildings,” she said. “So tall! My goodness! Look at them, Laura!”

We arrived in the mall lobby to find, to my great satisfaction, AN ESCALATOR. I convinced Aamaa to ride it, leading to one of my favorite pieces of Nepal footage in fifteen years.

The escalator, I am pleased to say, is followed by a ride on a glass elevator.

We stay on the rooftop as dusk settles, eating appetizers and gazing out over the city, which stretches off smoggy and hazily lit. The next day, we will do some shopping in Assan Bazaar. Aamaa needs a few pieces of clothing, and I need a container to burn the incense from Solukhumbu that Sonam sir gifted me when I bought his tea yesterday. Prem Binaju is in Kathmandu with a client, and he’ll guide us through the crush and throng of shoppers and vegetables and piles of Himalayan rock salt.







We only have one night in Kathmandu. I wake up in Aparna didi’s house to early morning light filtering through the sheer curtain as street sounds muffle their way in to our room. Aamaa is lying on the other bed, a place I never ever find her in the morning, because she gets up hours before I do to milk the buffalo, start the fire, heat water, and prepare for the day head.

“Get up Laura,” Aamaa says, lounging on her arm in an exaggerated display of leisure. “Let’s get to work.”


Keys and Threes


Thirteen days ago, Butu bouju’s father died. Out of all the possible things that might have been happening today, the whole community was gathered at Butu Bouju’s house for the last day of kriya. As the sound of the priest reading propagated over the arrival and bustle of visitors, Butu bouju’s house had that particular feeling of the world being unveiled after a deep and intense period of ritual mourning. Aamaa and Pascal and I pulled up plastic chairs in on the patio, where many relatives had come to pay respects. So the chance for us to be with family and community before our departure across the world was brought about by a death.

“How are you both? Laura, when did you arrive, when are you leaving?”

“We’re leaving for America today,” we told everyone. “We’re both going.”

Bhim arrived. We haven’t seen each other in probably three or four years. This November will make fifteen years since Bhim first brought me to a small house around the corner, where a widow and her daughters were living, and offered to have me move from his household to theirs.

“You’re taking Aamaa to America?” Bhim asked.




Bhim shook his head and smiled with that ironic twinkle he gets sometimes when I’m just not figure-outable. Which is a lot of the time.

“This has been a long story,” Bhim concluded.

“Yeah,” I laughed, “it has.”

“Tell Bishnu hello from me,” he said.

We left the kriya and went home to finish organizing. I’ve left this house nearly twenty times, and always the leaving is leaving Aamaa. After that, it’s just physically departing from Nepal. Bringing Aamaa along feels like bringing the house, and I’m not to sure how to pack.

Something else strange – the quiet. One of the things I remember from when Bishnu left in 2008 is how crowded the house was with people on the last night: neighbors, uncles, relatives I’d never met before and have rarely seen since, they were all crowded on to two beds, talking and laughing. In most households, when a family member is going abroad – “outside,” is the word people use – there is a great deal of activity. But Aamaa’s house is not a usual household. There’s nobody else in it.

So as mid morning became afternoon, it was just us, wondering how to ready the house to be without its mother. I swept and Aamaa put the mattresses up. It was unclear what else to do; I just wanted it to look organized. Like we’d prepared something.

Sonom sir came down from the Resort. I’ve bought six packets of local tea that he grew in the resort gardens behind our house. I hang out at the Resort now and then, to jump rope or do qigong, to chat with Sonam sir and his wife and nephews. Many of my friends have stayed there over the years while visiting me. Sonam sir’s family is from Solukhumbu, and like me, they are outsiders who have their custom-made place in Kaskikot.

“Good journey,” Sonam sir said, giving Aamaa and I each a kata in the Sherpa tradition.

Throughout the prior evening and afternoon, there was one person who spent a good amount of time sitting with us: BAA!, Mahendra’s father. Our cranky, sarcastic, exhausted neighbor, the one whose missing teeth prompted my career in delivering rural dentistry to underserved people. From the time I first came to Kaskikot, BAA! seemed unapologetically resentful of my unearned privilege in the world. He and Saano didi’s husband often function as the men in our house, chopping branches or negotiating social matters that require representation by men. Over the years I’ve spent a lot of time with BAA! collecting branches or chasing the chicken while he watched me fumble or drinking tea and admitting that I don’t have any explanation for why the world is crap. That God gave me easy and he got dealt hard was never to be smoothed over or ignored. On some unspoken level, it wasn’t my fault, but I didn’t deserve any credit for being ahead, either. So we just collect branches and sip tea and that’s how it is. I took to calling him BAA! because he would point at himself and say, kind of demandingly, BAA!  Father. That’s how I was to address him, even though Bishnu and Didi call him “dai” or brother. At least he would be in charge of that.

Often our closest neighbors simply wander off when I’m leaving Kaski, as goodbyes are uncomfortable and pretty pointless, anyway, and at some point in the afternoon BAA! had indeed wandered off, and that was that. So I was surprised when he reappeared holding two silky white katas. He gave one to each of us.   BAA! will probably never see America, or probably anywhere outside Nepal. All the tourists come and go from this village and he is getting old with fewer and fewer teeth that I could not save, either.

“Go well,” BAA! said. “Take good care of Aamaa. And bring me back a son-in-law.”

After we’d done whatever we could think of to do, Aamaa changed in to the clothes that she’d hung outside in the shed the night before. Once her travel clothes were on, she couldn’t go back inside.  It’s also inauspicious to leave the house for a long journey in threes, so Aamaa left first, her bag packed with cucumbers and ghee and the CDMA phone for Didi and almost nothing to take America. In one of the strangest moments of my adulthood, Aamaa walked out of the yard and around the garden of cut corn stalks while I stood on the porch with Pascal, watching her go.

Then Pascal took a key out from around his neck and jammed it in to the wooden door. With that, he and I followed Aamaa up the little path, to the road, to the bus that will take us to the other side of the world.


Auspicious Leaving


Our flight to America was scheduled for a Monday night, but finding a day to leave the house in Kaski was a problem. Generally speaking, Saturdays and Tuesdays are inauspicious days to leave one’s house for a long journey (although on Tuesdays, you can get away with it, but ideally you shouldn’t stay at the house you are going to). Plus, Aamaa has a special restriction on Mondays that doesn’t necessarily apply to everyone: she is so much a part of her house, so rarely leaves it, that Mondays are off limits too when it comes to locking the door and saying goodbye. That left us with Sunday morning they day before our flight from Kathmandu as the only viable date for departure. And then it turned out that was ahmse ko chatujasi, a monthly position of the sun that is inauspicious for leaving one’s house. Sunday was a non-starter.


The solution we came to was that Aamaa would put her packed bag outside the house in the early hours of Saturday morning, before it was fully Saturday.

I arrived back from Cambodia on Friday evening with Pascal in tow, and found the corn cut down. We did all the usual things – making dinner, playing with Amrit and Narayan from next door, chatting with neighbors passing through. Aamaa set to arranging things in a small shoulder bag. Two saris, two blouses and a petticoat to wear with them, and the two new kurta salwaars we had had made. What else should she bring? The bag looked disconcertingly empty. I show up in Nepal with two large duffel bags every time and most of my wardrobe lives here. What do I usually have in there? Can that give us any clues as to what Aamaa should add to her bag?

A sweater for the plane, I suggest. It is cold in the plane.

Mostly Aamaa was concerned with what items we would bring to Didi in Pokhara tomorrow. An enormous cucumber the size of a cricket bat. A bottle of heavy ghee (and a collection of smaller bottles for Bishnu, Mom and Dad, Ricky’s family, and me.). Aamaa’s CDMA telephone needs fixing, and besides, someone might call it while we are in America – we were to leave the telephone with Didi. Most of Aamaa’s bag was filled with things to be left in Pokhara.

“Laura, set your alarm for 3am.”

“I set it.”

The evening wore on, our last evening, the one where normally my bags sit threateningly zipped and ready, signaling the splitting of our worlds. Instead we just fell asleep, wondering what is going happen next.

“Did you set the alarm?”

“I set it.”

We drifted off. My dreams wove in and out, waiting for the alarm. Finally I opened my eyes. It was 4am.

“Aamaa, wake up.”


“The alarm didn’t go off. It’s 4am, go quick.”

Aamaa took her hand bag and hung it outside in the shed. The phone and other belongings were allowed to finish the night in the house, but the clothes she would travel in needed to leave before daylight betrayed them.

I drifted off again, the feeling of uncharted territory hanging softly in the pre-dawn.


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.


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













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.


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 produces 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.