You’re White. It’s Fine, But Own Up.

 

It’s no secret that I am not a big proponent of health camps – for all the obvious reasons.  Despite the very quantifiable benefit of a rapid delivery of emergency care in remote places, we’re working in a different space, trying to uproot transience, lack of accountability, saviorism, and the indignity that in the final reckoning still goes with things like…well, health camps in rural developing world communities.

I know this seems unrelated, but I remember a day back in 2004 when I had made my morning run to the junction at Naudanda, and a bus was just pulling up along the Bagloon Highway.  Some tourists got out and they had a collection of enormous plastic bags from which they began extracting articles of clothing.  A crowd of people gathered around, reaching for the anonymous pieces, irrespective of size or relevance or history or purpose.  Just in case something was useful.  As I stood watching, my running shoes expelling wafty dust from the dry road, there was no analysis or judgement that went through my head; I was just frozen by a wave of shame in my heart.  For the indignity, the dehumanization, the unspeakable power differential before my eyes, in which I was complicit.  For the participation we are all assigned before we’ve even arrived: savior, beggar, observer.

There was never a time in my life when I thought, you know what my passion is?  Dentistry!  Working in oral health was something that grew out of being assigned the observer role, which turned out to be very uncomfortable.  I’m more in the business of looking at casting and lines, of trying to rewrite parts of the script.  Oral health is an ideal area to be working on this because disease is so prevalent, chronic, and preventable, with services disproportionately skewed toward upper classes (globally, not just in Nepal). This is an area where it is entirely possible to create a system that does not rely on helicopter interventions organized to address the greatest volume of teeth, but relies, instead, on structural accessibility and strong public health policies.

I’ve had a decade and a half to grapple with the problem of myself as a white person working in an underprivileged country.  What I realized pretty early on is that the only way to handle that is to embrace it with all four of your limbs and hang on tight for the whole ride. Centuries of colonialism have conferred on my skin and nationality a power and predicament that none of us, in the current act, created or can do away with, which only leaves us the option to be honest about the whole clumsy issue.  The way this translates is that I think carefully about when and how I show my white face, and in fact, this is not an uncommon topic of discussion in our office when we are planning fieldwork. Over the years I have mostly built myself into a behind-the-scenes role, while Nepali people fill all the stage characters. But when it’s strategic, our team openly brainstorms over how my whiteness and Americanness (two, not one, power plays) can be leveraged to bring legitimacy to others or bend things in favor of a local agenda. That is what these privileges should be used for.  In fact, shirking that opportunity seems almost as problematic as not knowing when to stay out of the way.

So, if you are staying with me here, we have on one spoon some peanut butter (health camps, with their historic problems) and on the other some jelly (colonialism, lending power and privilege to white foreigners), and we are about to make a kickass sandwich.  Are you ready?  Welcome to the promotional community-based dental camp. We did this last year in Hansapur, almost by accident, when we arranged for fifteen foreigners to go do a survey, while six Nepali dental technicians set up a field clinic and treated 300 people. The result was that Hansapur asked us to help them start a local dental clinic and school-based oral health programs with providers of their own.

YOU GUYS, we thought. This is a good idea.  This is an excellent use of a brigade of white people.

So this year, for Nepal Smiles 2.0, we flipped the agenda.  The purpose of the camp is promotional, and in the mean time, we’ll do a survey, treat some patients, get extra supervised field training for our technicians to cap off their week of professional development.  But the primary goal is to expose a rural community to resources we can help them develop, while a large group of outsiders adds legitimacy by being part of the process.

Welcome to the village of Dhital.

In the promotional community-based dental camp, our agenda was explicitly not to save all the teeth in Dhital. This is quite a different stance than your typical health camp.  We limited patients to fifty, so that technicians would be able to properly go through the entire respectful assessment and treatment planning process they had practiced all week. We invited politicians and social leaders in Dhital to observe the treatment room and meet our field teams from other villages. All services at the camp were provided by technicians and assistants from surrounding villages while Dr. Bethy consulted on the learning from the week, lending her stature as well as her expertise. As patients came through the camp, we treated a limited number within the constraints of this approach, and then provided referrals to our partner hospital in Pokhara.  We accept these limitations because we are also laying out a pathway for Dhital to launch its own similar services.

 

 

 

 

 

 

 

I have been mulling over this quite a bit and would love to see this conversation happening out in the world.  What do you think?  How do we negotiate a racial story that has been hundreds of years in the making, and leverage it to make a more equitable world?  Surely, there are people out there ready to rip this conversation to pieces.  But we should have it.  What I see daily is that, for rural Nepali health care providers like those we train, being associated with people from California and New Zealand confers legitimacy. Hand-wringing over this is less useful than taking responsibility for these roles we’ve been cast in, and unflinchingly examining how we play them in a way that ultimately deconstructs them, chips away at the hard shell of racism and colonialism, and eventually, creates new a revised and more just theater. This is not something that happens by accident, or quickly or easily, or without mistakes.  And definitely not without calling it out in the first place.

Here’s us, having our imperfect go.

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Out of Crisis, Into Treatment Planning

 

While half of us were out in rural areas doing focus groups and school/shopkeeper observations, all the technicians and clinic assistants were back at the hotel doing a week-long professional development training with Dr. Bethy. They spent each morning in classroom learning and each afternoon treating patients. (Thank you, Kidasha, for partnering with us and allowing us to work with children and adults in your program during our practical sessions!)

The basic training that is provided to our dental technicians was developed by the World Health Organization and is called the Basic Package of Oral Care. It’s just a few weeks long and focuses, logically, on teeth. Trainees learn how to place atraumatic glass ionomer fillings without electrical instruments, and to provide certain types of extraction. Over the years we have done a lot of innovation to take the Basic Package of Oral Care and contextualize it in a rural clinic, developing our own infection control and clinic-setup protocols. Last year when Dr. Bethy and Dr. Keri came for the first time, we added to the treatment package fluoride varnish and an arrest-carries technique with silver diamine fluoride (which, having just been approved by the FDA., is up-and-coming as a new treatment in the U.S. but has been in circulation in developing countries for a long time). With this range of interventions, our dental technicians can address a wide array of conditions in the remote areas where they work.

Beginning last spring with Dr. Keri, we started looking beyond teeth at treatment of the person. This means addressing not only a problematic tooth, but the disease process that is happening as a result of infection, lifestyle, and other factors. It requires looking at the entire mouth, including early-stage decay that might not yet be bothering someone, and setting up a plan to restore the health of the individual through a combination of comprehensive treatments and lifestyle adjustments. This way of practicing the Basic Package of Oral Care represents an enormous leap forward for our dental technicians and for the care delivery model we are trying to establish.

Over this last week, Dr. Bethy’s training took the skill of treatment planning to a whole new level. The technicians and clinic assistants got five and a half days of theory and practice in which they examined case studies, developed a treatment planning form, and explored how to make treatment decisions with a scared or resistant patient. Continuing with Keri’s lessons from last summer, the training examined ways to respectfully and sensitively approach children, who are often terrified to have someone examine their mouths, much less conduct treatments.

Our goal with all of this is to move out of crisis management and in to disease management in a way that looks at the entire person – yes, even for the rural poor, in regions with no running water or electricity.  I really can’t understate how progressive this approach is in an environment that trends at every institutional level toward delivering short-term, emergency relief for millions of people living in rural poverty.  Following this winter training, technicians will now complete treatment planning forms for each patient, allowing them prioritize and schedule interventions over a series of visits. In addition, working with Dr. Karen’s group has infused our program with a new focus on nutrition and lifestyle contributions to oral disease, so our children’s programs are going to start including junk-food free school zones and collaboration with shopkeepers to sell healthy snacks.

 

 

 

 

 

 

 

This is all still very much a work in progress, but when I came to technician training on Saturday, I filled with pride. The fact that our technicians are grappling with these questions is itself innovative. Back before this project even had a name, it was about elevating human dignity through access, consistency, and respect. That’s why it didn’t matter that none of the founders were expert medical practitioners. That we are having five-day trainings with community dentistry experts on how to factor in the amount of time it takes someone to get to the clinic, or their age or belief system or level of fear, is a remarkable level of sophistication. And yet, I firmly believe that this can and should be a system-wide standard.  As much as this is a set of clinical skills, it’s fundamentally a mindset.

And it’s doable.

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Better Questions

 

After getting our first study with UCSF-Berkeley students under our belt last winter, this year I had the chance to work more closely with the lead student, Tanya, to help design a qualitative research project I’ve been wishing someone would do for a long time: conduct focus groups in rural areas to explore people’s lived experiences of their health care.

The reason I was hoping that Tanya would use her fellowship for qualitative research is that there seems to be a lack of rigorous investigation of health practices from the perspective of populations like those we work with in Nepal. In a talk I gave at UCSF last spring, I suggested that research agendas tend to be set by institutions that are far removed from marginalized communities, even when those communities are the target of the research (a phenomenon that is, in fact, its own area of critical analysis in human rights literature – no points to me for coming up with that).

Focus group prep with students and JOHC field staff

The result is that too often, resources are directed at research that serves the researchers instead of the development of better health care structures in places like Nepal. Worse still, whether or not we realize it, academics sitting in California or Ohio or Connecticut designing research questions about people in Rupakot, Nepal, are inevitably influenced by implicit biases about rural, non-western, non-white poor people. The result is an overage of studies on things like shamanism and use of medicinal chewing branches, and a lack of documentation on what drives people to practice inadequate oral hygiene even though, in point of fact, modern hygiene products like those in your own bathroom are widely available in rural Nepal and people already know how they should be used. This bias in research then translates to poorly conceived interventions such as distribution of free dental care products and lessons on personal hygiene, even though that’s not addressing the causes of disease. From a human rights standpoint, this result is demeaning.  And the overall dynamic preserves research institutions from the voices of marginalized communities and a responsibility to legitimize non-academic perspectives.

This year Tanya and I worked together to design focus group questions that would lead to conversation among rural residents about their actual beliefs and practices around health care. In Jevaia we’ve seen through years of trial and error that understanding people’s perceptions of their resources is as important as what those resources are. The focus groups will look at how much residents feel oral disease matters and why, and try to break down the choices that villagers make about both daily hygiene and seeking of treatment services. Knowing how little up-to-date research of this kind exists in Nepal, I am really hopeful that Tanya’s study will provide a foundation for more relevant, application-oriented quantitative research in the future.

So here you have it – our focus groups! The first was actually a presentation of last year’s study to the villages where last year’s students collected the surveys, in Puranchaur and Hanspaur. Then we had a lengthy and very informative discussion with leaders and teachers from those areas about the meaning of the study results.

The second and third focus groups were in two areas where our project has completed the two year seed cycle and the clinics and school programs are continuing in the handover phase.  We did two parallel focus groups in each location, and our Jevaia field staff took roles as facilitators and note takers, which is was a great professional development experience for them (and me!).

Bharat Pokhari

Salyan

 

 

 

 

 

 

 

 

The fourth pair of focus groups was in an area where our program will soon be launching, in the district of Parbat.  Finally, the last was in an area we’ve never worked in before, called Dhital, during our promotional camp.  By this time, our facilitator Sujata and I were really in the groove…

Note taking at the Dhital focus group facilitated by Sujata

In each of these, I took a job as an official note-taker, which gave me an awesome opportunity to listen in closely to what participants had to say. I learned that there is a very high level of awareness that sweets and junk food cause oral disease, and also that parents largely feel helpless to control their children’s junk food intake. I heard some things I expected, such as that basically everyone already knows you are supposed to clean your mouth twice daily, and that products to do this are available and affordable, but that for some reason, people don’t do it anyway. Some of the groups began to get in to nuanced discussions of why that is which were totally fascinating.

Important for us, many groups talked about treatment-seeking behavior. There was categorical agreement that this only happens when there is pain that is impacting someone’s ability to function. People felt that traveling to a city was a significant burden and that proximity of services was a major determinant of what kind of treatment they would seek. There was a widespread awareness that dentistry is a vaguely dangerous and poorly regulated practice, and that you can never be certain that a provider is qualified.

A few of the groups I was in veered in to more practical brainstorming once the official “focus group” discussion was over. These conversations ranged from funding their local clinics to requesting clarification around beliefs raised in the focus group (for example, dangers of blindness from dental care). One group even asked for a proper brushing lesson, so our Sarangkot Clinic Assistant Renuka, who was acting as a note taker, got up and gave an excellent demonstration right there in the focus group!

All around, this was a GREAT learning experience for all of us, and I hope it will produce some pretty solid qualitative data on health beliefs and practices in these areas.  Super proud of our whole team, especially Muna, Gaurab and Rajendra in the office, who organized an insanely complex tapestry of logistics to to make this happen.

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Welcome Back, Universities!

 

TADA! The Berkeley-UCSF-UP gang has arrived, and today we had our all-team orientation to the upcoming week. Look how many of us there are!! I can’t tell you how much I love this. Some of the field staff joining us this week are from villages where our program has been closed down for a year or two and is soon to be restarting, and I haven’t seen them in a while. Seeing them walk through the door with smiles and hugs was glorious. There is nothing like watching our team leaders and technicians and clinic assistants trickling in to a hotel in Lakeside from three districts, and then sitting interspersed with international students as the expert parties on rural oral health promotion in Nepal. Just the fact of seeing all these people in one place makes my heart soar.

We’ll be running five concurrent projects this week:

  1. Four-day Clinical Training for JOHC technicians and clinic assistants with Dr. Bethy
  2. Oral health focus groups in rural areas
  3. Observations of schools and shopkeepers in rural areas to assess nutrition habits
  4. An oral-health status survey conducted by a British student joining us from Barts and the London School of Medicine and Dentistry
  5. A promotional camp where students will do a survey on maternal and child health and nutrition, and technicians will treat patients to demonstrate our rural dentistry model and finish off winter clinical training

At our orientation, Dr. Karen shared the results of last year’s study, and I presented our program model to the visiting students. We played games to get to know each other and went over the plan for the week. In the afternoon, we divided in to groups according to project stream, and the technicians began their first half-day of clinical training with Dr. Bethy.

And, the shirts fit. PHEW!

Nepal Smiles 2.0

 

I’ve just arrived in Nepal for our second research and training collaboration with students and faculty from Berkeley, UCSF and the University of Puthisastra in Cambodia. Last year, this was a blast, brought me amazing new friends, and created my first chances to present our work internationally in California, India and Cambodia. This year we have a big group of sixteen people descending in to our Pokhara valley to five overlapping projects over the course of a week.

Getting ready for this research collaboration is, and was last year, somewhat like putting on a Broadway show. In the office we currently have just three full time staff, and they are responsible for getting all of the necessary government permissions in place, mobilizing unofficial social leaders whose support we need in rural areas, recruiting hundreds of participants for focus groups and surveys, securing transportation to remote villages (the entire group fills two buses), organizing food in rural areas where we can only eat at people’s homes, and not least of all, coordinating with our nearly 20 field staff to make sure everyone shows up from their respective villages for a week. On top of that, we need to design and print 40 logoed shirts, get hundreds of survey printouts, and translate multiple documents between languages. Our amazing office team of Muna, Gaurab and Rajendra manage to steamroll through all of this while keeping our regular work afloat across ten villages.

My role is to keep the different project streams sorted and to bridge between our foreign visitors and the reality of the ground situation in Nepal. I have an excel file featuring no less than ten tabs, tracking everything from hotel rooms to project leaders and bios to budgets. This is because, let’s say we need to buy 40 printed sweatshirts. That seems simple (nope), except that we have people ranging in size from Soba, our Team Leader in Sindure who is about the volume of a pencil holder, to me at 5’8” and a dozen foreign students of various heights and widths. So figuring out what sizes to order and then finding someone who can give us such a large quantity of them and print them on time is an entire spreadsheet. Everything gets more hectic when you are multiplying gaps in planning by 40, dropping them in the gap between two languages, and adding in the overall entropy of the Nepal environment. Do you know what happens when you show up with three dozen people for a project at an empty community building at the top of a hill and you didn’t think to plan ahead how many chairs you might need there? Or, let’s just say you don’t have enough pens?

Chaos, my friends. Chaos happens.

Appreciate my spreadsheet

Appreciate my spreadsheet

I will write about the different project streams of this year’s collaborations in upcoming posts. But they include focus groups, observations of schools and shopkeepers, a survey on maternal and child oral health and nutrition, an oral health status survey being conducted by a British student who has also joined us, and last but not least, an ENTIRE WEEK OF TECHNICIAN TRAINING which I am so excited about I can hardly handle it.

For now, here we are just after I arrived in the office yesterday. I sat down to debrief with the team and doled out Amercian candy and Race to the Rock tshirts. Within a short time, my two favorite creatures came busting through the door and started stuffing all of the office candy in to both their faces and their pockets. Before the performance begins this week, it was lovely to land here in our red-carpeted office and find this cheerful team, to listen and observe as they jammed about how hard they’ve worked to support each other with this complex preparation, and to see the pride they are taking in seeing things come together. It is a wonderful feeling to see our tiny but mighty team take on a cohesive identity as host to visitors, and I especially enjoyed the trill that these three were getting out of how much more they know about doing this than they did last year.  We are all on a steep and exciting learning curve as we introduce the world to the efforts we’ve been making here over these years.

Ok ok ok ok…bring it on!

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