Monthly Archives: December 2019

Around Town, Nepal Life, Oral Health Care Project, Work

A Piece of Christmas Cake

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For about two years now, we have been hard at work lobbing the new province government for health policy that includes primary oral health care. I’ve found myself hesitant to blog about many of the twists and turns in this aspect of our journey because political issues feel so sensitive while they are unfolding. And yet this phase of our adventure has produced some of the most colorful, absurd, harrowing and triumphant experiences we’ve ever experienced. Advocacy is, after all, a combination of showing up at government offices, making connections, making connections from connections, inviting people out to see our work, giving presentations, writing policy recommendations, rewriting policy recommendations, cajoling officials for meetings to discuss policy recommendations, and drinking tons and tons of tea and coffee over many coffee tables. These activities are exciting enough in a well-established, stable government. We are working with a government that is has been in perpetual transition for decades, with roads that wash out, with wise men and power saris, with astrological events that dictate the movements of both presidents and wedding parties.

I mean, all kinds of things happen. It is a shame not to tell you about some of them, some of the time.

Recently, we had a breakthrough: Province #4, ours, re-established a previously defunct “Basic Oral Health Training” for primary care providers. We spent almost all of the summer of 2018 madly campaigning for this training. The five provinces of Nepal and the provincial government structure itself had at that time only recently been established – prior to 2017, the federal government was sub-divided by 75 districts – and it would still be some time before personnel had their job parameters defined in the new structure. But our efforts that summer eventually paid off, and recently, through a winding chain of events and people, writes and rewrites, submissions and resubmissions, and patience possible only thanks to some amount of beer, a province-level Basic Oral Health Training budget training descended from the heights of government.

The training is not actually designed yet, so it is fragile and easily gutted, but this also our first major policy breakthrough at a high level of government. It taught us a ton about collaboration, persistence, and the emerging structure of Nepal’s new decentralized governance structure. Even this small-big step would have been impossible to accomplish by working alone.

So this winter, our sights are trained on the Province Training Centre, where the official Basic Oral Health Training will be delivered. This training has a long history in Nepal that I will share at a later time; suffice to say that the essential focus of Jevaia over the last decade has been implementation of care after health care workers have taken Basic Oral Health training that’s provided outside our organization. So by nature, our role has involved a lot further training and refining of skills. If there’s one thing we’ve been up to our, um, teeth in (sorry it was too easy), it’s training and professional support for midlevel providers to do “basic oral health care” in Nepal’s primary care system. That’s why we exist, and it’s how all of our health post clinics and community programs survive against tremendous headwinds.

Now, as you can see this is all very serious business, and our recent meeting at the Province Training Centre rose to the gravity of the occasion. With this shiny, hopeful budget allocated, it is essential that we lobby for a training program that reflects what we’ve learned in over a decade of up-skilling midlevel providers to deliver rural oral health care. So we printed out materials. We reviewed key strategic points. We went to the Province training center.

“You guys!” Rajendra, our Medical Coordinator, cried as we crossed the threshold of the Province Training Centre, examining his feet with a mix of alarm and delight and curiosity that is unique in this world to Rajendra. “I’ve worn the office slippers!” He giggled, and then looked shocked, and then giggled again. Indeed, a brief review of Rajendra’s feet confirmed that he was in fact wearing a pair of the shower shoes we use inside our carpeted office, and his sneakers were still safely stowed on the shoe rack by the office door.

I began to giggle too. “Maybe nobody will notice?” I said.

“Sita Ram sir!” Rajendra announced to our Program Director, excitedly. “I’m wearing the office slippers!” He couldn’t help it. He’ll agree with me when he reads this.

We were led in to the office of the government’s oral health Training Coordinator, where we left our shoes and shower slippers at the door, conspicuously not blending together.

We had a lengthy, complex, and sometimes coded meeting with the Training Coordinator. We were thrilled to find out that a technical working group is to be formed and we are invited to send a representative. The Training Coordinator requested that we also submit an evidence basis for our recommendations, and I will spend the next week compiling a selection of scientific literature around an “augmented Basic Package of Oral Care.” (For you nerds out there, the BPOC was developed with the support of the World Health Organization back around 2003 and is well documented in the literature; meaning we didn’t invent it, our business is to translate it in to practice in the face of real-world challenges.)

From the Training Centre, we re-donned our shower slippers and moved to the Health Division, the government department the Training Centre sits under. There, at the door, we ran in to none other than our past Jevaia program director! Nabaraj now works as a training coordinator in the province offices – perhaps a hopeful sign for us. We were warmly welcomed and led in to a cavernous office with an enormous with a desk at one end, and, per Standard Operating Procedure, tons of couches arranged against all free wall space. The couches were populated by a dozen or so visitors, people we didn’t know, who were both together and separately in an ambiguous state of meeting with the official we had come to see: The Health Directorate.

We took up arbitrary seats on couches where seats were available. This scattered Sita Ram far on a westward couch, while Rajendra, Rajendra’s shower slippers, and I secured side by side perches on an eastward couch. From there on out, in order for us to talk to Sita Ram, we had to either sign or speak very loudly over cross-talk from the northward visitors, who occupied the longest line of couches and either were or were not meeting with the Health Directorate, and may or may not have all been a single group with a unified agenda. There was no way to tell. Luckily, our former director Nabaraj was able to sit nearby me, on the adjacent westward couch, with only a fat faux-leather arm separating us, which made for good chatting and time to assess the situation.

We remained in this configuration for some time, until the room quieted and, based on a cue I could not identify, the Health Directorate affably invited us to introduce ourselves.

All of the people on all of the couches remained at their stations as we took the floor from our arbitrary seats among them.

Sita Ram went first, and then Rajendra. And then it fell to me to introduce myself and provide a general history and outline of our project, and why we were at the Health Division. In Nepali, with all the important couches watching.

The Health Directorate was gracious and curious. He asked us a series of astute questions about the need for primary oral health services in Nepal and about evidence and evaluation for our project model. He has a PhD in the sciences and absorbed our answers thoughtfully.

“You are here,” he said, “at the right time.”

We held our breaths. This was a good start.

Suddenly, the door opened and a group of men walked in.

All the heads on all the couches rotated toward the door.

“Namaskar, sir!” exclaimed a young, brisk man at the front of the group. The Health Directorate rose to meet them.

“We have brought you” –the young man held out a package, importantly– “a Christmas Cake!”

A murmur rippled across all of the couches of people. The Health Directorate reached out to receive a festive box. He thanked the men profusely. Without disrupting our key role as a riveted audience, I was able to lean over to Nabaraj and deduce that the men had come from a local hotel where the government hosts many of its meetings and gatherings.

“A Christmas Cake!” exclaimed the Health Directorate. “How wonderful!”

“How wonderful!” hummed the Couch Sea.

It was decided in short order to adjourn to the next room for Cristmas Cake. The entire room of people rose and passed through a door behind the Health Directorate’s desk, which led us in to a board room with a long, shiny table. The Health Directorate sat down at the head of the table; Rajendra, Sita Ram and I took seats all the way near the other end, and the as-yet-unidentified substantial company filled up the positions in between. The hoteliers huddled around the Health Directorate and bowed their heads over the Christmas Cake box, which was opened delicately to reveal a white iced fruit-cake with a neat candy-cane trim.

Paper plates were produced out of nowhere.

The Health Directorate began the careful process of dividing the roughly 6-inch cake in to precisely calibrated slices for the large room of attendees. Each offering was gravely placed upon a paper plate and passed to the right. Each person then continued passing the plate until it had circulated the long board table and ended up with the person sitting to the left of the Health Directorate. The Christmas Cake circulation continued thusly until all had been served. To the best of my knowledge, there was not a single Christian in the room, including me.

“What delicious Christmas Cake,” we cooed in turn.

Back at the office later, everyone wasted no time in celebrating the shower slippers for their trip to the Province Offices today. “How’d it go?” the rest of the team asked.

“Amazing,” we said. “We have no idea what happened.”

I sat down at my desk to begin compiling our package of research articles.

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Aamaa, Between Worlds, Didi and Bishnu, Family, Nepal Life, Reflections

Tuli Aamaa

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On December 12, Tuli Aamaa died. She was 94 years old and has been one of the oldest, most endearingly tired people I’ve ever known since I first met her seventeen years ago. Tuli Aamaa means “big mother” – in Nepali culture aunts are mother-figures, and they are either big or small depending on whether they are older or younger than your parent. Bishnu and Didi’s father was the youngest of five brothers, and Tuli Aamaa was his older sister-in-law. So she was our Big Mother.

Tuli Aamaa and her husband had settled down in the valley, just where the jungle path dumps us out on the highway in Pokhara. So when she came to visit us in Kaskikot, it was usually early in the morning, and she walked up the entire jungle path, a route that takes me about an hour of climbing at a good clip.  Tuli Aamaa would arrive with her walking stick and a litany of woes. These woes – and Bishnu will back me up on this – would have us giggling within minutes of her arrival and for a good while after she left. In a breathy exhausted voice, high pitched but only in the range of a dull butter knife, Tuli Aamaa would tell us, and anybody who was around, perhaps even the chicken or a wooden post holding up the porch or, barring these, the morning breeze, that everything was wrong with her, and it was enough already, it was time for her to die. She never looked pleased, and yet this activity brought her such return of satisfaction, or perhaps relief, that she hiked all the way up a mountain to participate in it, and then all the way back down the mountain a few hours later. It was wonderful.

Amazingly, Tuli Aamaa has always been the oldest person in the world, and she never got older. She looked just as old in 2005 as she did when I saw her last February, in 2019.

Tuli Aamaa with baby Pascal in 2005.

Tuli Aamaa with baby Pascal in 2005.

Yesterday, on the solstice, Didi and Pascal and I went out to Tuli Aamaa’s house, where her relatives are sitting kriya, the thirteen days of mourning. We sat outside talking with her son Ram Chandra dai, and found things here and there to help out with as callers came in and out of the house. Didi helped Tuli Aamaa’s daughter in law Tara bouju prepare her daily meal, which has to be cooked in a single pot during the kriya period.

And then the three of us left to walk up the jungle path, along the route that Tuli Aamaa always took to visit us. It’s also the way that Aamaa climbed after she gave birth to Didi 42 years ago in Tuli Aamaa’s fields. Aamaa took refuge briefly in Tuli Aamaa’s buffalo shed, before carrying her newborn, our Didi, up the mountain the very day of her birth. I have always been captivated by this story, but today it seemed phenomenal all over again, the traverses these generations have made over these stones. Pascal bounded up ahead of us, and found some luxurious blue maiyur feathers, and wanted me to take his picture with them behind his mom, standing on the same stones his grandmother once carried her over.

Later, I unearthed a picture of Tuli Aamaa’s field, and her famous buffalo shed, that I took when I was first introduced to these climbs and their histories back in 2005…

…and then I found one I’d taken the same day, in 2005, of Tuli Aamaa in the buffalo shed where Aamaa and Didi spent their first incredible moments together.

She looked just as old in this photo, as ever. As far as we could tell, she was always ready for this day, that to the vast majority of human beings seems a cliff edge, but to her was only another day.

We’ll miss you, and your loving, irrepressible climb through this world, Tuli Aamaa.

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Aamaa, America, Dali (Serena), Didi and Bishnu, Family

Baby Oil

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Aamaa and I landed in San Francisco in mid-afternoon, and Youba came to get us at the airport. It’s hard to imagine that exactly two short years since Aamaa’s first visit to the US, Bishnu has gotten married and had a baby. Little Serena Dali is still just a month old and she doesn’t yet weigh six pounds.

Aamaa and Youba, of course, had never met in person before we arrived. Bedraggled, we emerged from the airport, and Aamaa and her son-in-law looked past each other and shuffled their weight, unsure how to introduce themselves without the normal directives of a proper setting or the customary procedure that goes with such a meeting. Nepali mothers don’t meet their son-in-laws for the first time with nobody else around, at Door #4 of airport arrivals.

“So, um…hi,” Youba offered. He had gallantly driven through Bay Area traffic at rush hour to retrieve us, and now we had to get through rush hour Bay Area traffic in order to get home and take a nap. I was tired and grumpy wanted to sit alone being antisocial in the back seat. 

“Aamaa, you sit in front.”

“No way, you sit in front.”

“Come on, you and Youba can—“

“Nope,” Aamaa replied, and annexed the back seat of Youba’s Honda before any further negotiations could be held.

When we arrived at Bishnu’s apartment, of course, baby Dali was all bundled up waiting for us. We immediately took our first US-side family photo.

I am staying in San Francisco for a week before leaving Aamaa and Bishnu and Dali and Youba to head back to Connecticut for the fall. So we’ve got about eight days together to hover over the baby and deploy a non-unified strategy of obsessing over competing certainties about what to do with a baby.

Even though it’s obvious, we’ll state right off the bat that I am on the lowest rung of qualifications in this debate by many orders of magnitude. The baby did not come out of me and I have never raised one. Bishnu comes in at a solid second place since she’s the one who made the human. But in the lead, Aamaa is Aamaa. She raised Bishnu and Didi and two grandsons and she runs shit. The issue is that the shit she runs is usually in Nepal and we are in America and I come in first place at being American, thus resulting in a rare case of circular cross-continent baby-doting logic that cannot be solved.

Let’s take the matter of baby massages. It is traditional for Nepali mothers to massage their babies with mustard oil a few times a day, usually in front of a fire where they can warm the oil and warm their hands. I watched Aamaa drip oil in to Aidan and Pascal’s eyes and ears until they were well past toddlerhood. This is thought to be good for the baby’s development. 

As we were unloading our suitcases, I extracted a few 2-liter sprite bottles that Aamaa had filled with ghee. I admit I knew these illicit items were stowed in my luggage and I consented to the, um—smuggling—for the sake of the baby. But then—Lo!—a two-liter bottle of mustard oil was discovered next to my shirts. 

“You can’t get good mustard oil here,” Bishnu explained. Yes, these two were in cahoots.

“The oil massage is fine, but no oil in the eyes and ears,” Bishnu told Aamaa.

“Oh god, definitely no oil in the ears,” I squirmed. “And the eyes are out of the question.”

“La, la,” Aamaa murmured.

Aamaa set happily to her oil massages. However: we were missing fire. She would sit in a patch of sun in the living room, but it wasn’t the same thing as having fire, and fire was needed.

Are you worried about where this is going? Be worried.

September in San Francisco is temperate to hot. Bishnu’s apartment consists of a small living room attached to the kitchen, and there is one south-facing glass door that collects heat all afternoon. When the door is slid open, it lets through a nice breeze. For fully developed human mammals like me, this nice breeze is refreshing and has other benefits such as abundant availability of breathable oxygen. But for Nepali babies, moving air is considered cold. ANY MOVING AIR. There is a general understanding in Nepali culture that babies should be kept warm, so much so that they are ensconced in multiple layers of clothing and hats even in the middle of the summer. I have tried to free many sweaty babies from their multiple baby hats when I’ve had occasion to visit with said babies in said season in Nepal. It’s futile; the babies are going to be re-swaddled and re-sweated immediately. But I’m intolerably hot and uncomfortable just looking at them in their hot clothes, so I try to free them anyway.

Seeing Dali bundled in layer upon layer of clothes and blankets in San Francisco raised my sense of temperature regulation distress to a previously unattained level. Clearly, American territory calls for American swaddling to American body temperatures.  Plus, the nurse who came by to check on Dali our second morning told Bishnu that the baby didn’t need to be put under so many layers and that the breeze was good for her. See, that’s what I said too.

So what this means is that each morning, I get up and crack the glass door – or sometimes just throw it open – and Aamaa runs to Dali in the opposite corner of the room to shelter her from the evil hypothermia-inducing fall breeze. Henceforth, we alternately, each when the other isn’t looking, adjust the glass door and Dali’s armor of clothing to our respective levels of comfort. This is of course an implicit pact. I know Aamaa’s going to undo my adjustments, and she knows the same, and the deal is that you have to respect the other person’s catastrophic approach to baby temperature maintenance by executing your improvements on the sly.

Advocating for your method, on the other hand, happens in the open and frequently. This is a lot of where Bishnu comes in. (Remember Bishnu?) Throughout the day, each of us loudly comments to Bishnu on why her baby should be kept hot or breezy. Bishnu tolerates this expertly. Both of our contradictory opinions are correct at all times. Bishnu is both too happy and too tired to care. We have nothing better to perseverate about. Everyone’s fine.

Now, the so-called absence of heat for Dali is particularly problematic during Mustard Oil Massage Time every few hours, due the aforementioned missing open-fire pit. On Wednesday, I go for a run. I breathe a great deal of healthy unimprisoned oxygen wafting off San Francisco Bay.  Hot and refreshed I enter the apartment to find the glass door sealed shut…and Aamaa puttering in front of the floor-to-ceiling central heating unit, which is going at full blast, and where I realize she has just given Dali an oil massage. The apartment is about 10 million degrees.

I stand in the door, probably with a friendly look on my face.

“What?” Aamaa asks.

“Are you serious, you turned on the central heat in the middle of summer and closed the door and we’re all gonna cook and die in here!”

“Oh, it’s warm for the baby,” Aamaa says innocently.

“Oh my God, Aamaa, ok…Listen!” I throw open the glass door. “In a week, I’m gonna be in Connecticut and you guys are going to do whatever you want. But for the love of God, while I’m here, can we have air for the grown ups to breathe?”

“La, la,” Aamaa says, satisfied. I do have to hand it to her for that round. 

The next day a package shows up from Amazon. Youba, bless his cotton socks, has ordered it.

Space heater.

For the rest of the week, and indeed as she will do for the next six months, every few hours Aamaa sits in front of the space heater in Bishnu’s room, which rises to five thousand degrees, happily massaging her squishy granddaughter. She warms her hand in front of the space heater and dips it in the mustard oil we brought from Nepal and presses it in to Dali’s tiny belly, cooing and giggling over her. Bishnu dotes around the two of them, delighted in their overheating together, and I pop in and out of the room reminding everyone that it’s much too hot for any normal person, and Aamaa answers, “La, la,” but I also have to take some pictures—they are so beautiful together and that space heater is so ridiculous and fantastic—and Youba sits in the living room letting us girls do what we do, and we are utterly content in our Dali’s world.

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