The Art of Not Knowing

 

(Re-posted from my June Newsletter – thanks for bearing with me if you are on my mailing list and are receiving this twice!)

Welcome to the Summer 2017 edition of American in Nepal Doing Dental Care and Other Impossible Pursuits.  This season will feature a number of high profile guests, including my cousin Sara and a return to the set by Dr. Keri the Pediatric Dentist from UConn.

Additionally, we have a nail-biting plot lined up for you.  First of all, last month Nepal held its first local elections in about 20 years.  Why are you biting your nails over this?  Because in working to change the health care system in rural villages in Nepal, the posse of bandits that is Jevaia Foundation spends a great deal of time building relationships with local government leaders, a quest peppered with uncertainty, adventure and drama. Presently, in addition to a fleet of newly elected politicians all over the country, there has been some government restructuring, and now nobody is totally sure about things such as who is in charge of distributing funds that were allocated last fall for stuff like, oh I don’t know…let’s just say rural dental clinics.  So, we literally have no idea what government we’re dealing with on day by day basis, and that’s about 75% of the reason we exist.

On that theme, two weeks ago I gave a short talk at my Williams College Reunion called The Art of Not Knowing (beginning at 29:45).  The other women on this panel were powerful ladies pioneering in the fields of journalism and feminism and are well worth a few minutes of time to listen to.  In my ten minutes, I talked about being a restless college student coming from privilege, women as athletes, and the impact of 9/11 happening my senior year of college as these things relate to my work in Nepal.

Back to other coming attractions.  In July Dr. Keri will be leading a second training for our technicians and clinic assistants, along with – TADA! – our new Medical Coordination Officer, hygienist Rajendra Sapkota.  With Rajendra’s help, we’re going to be strengthening our referral system with city hospitals.  We’re preparing for the launch of just one new clinic this year, in Hansapur, and the rest of 2017-18 will be devoted to revisiting our 8 established clinics, upgrading technician skills and equipment, and going back over the community and school programs in all of those villages.

Keri teaching, winter '16

Keri working with technician Megnath Adhikari last winter

And now it’s time for…a plot twist!  Three weeks ago, I’m in the car when Bishnu calls and tells me that she applied for a visa for Aamaa to come see her graduate from her Master’s program in Information Technology (that’s our Bishnu!).  And somehow, in some inexplicable alignment of cosmic unlikeliness getting turned around and coming out possible instead, Aamaa has scored a five year multiple-entry visa to the United States.  She now has the best visa in the family, and it appears that I when I land back in the US in two months, I will have Aamaa in tow.

[Insert sounds of Laura sitting in her car in the parking lot of Walmart, picturing Aamaa in her apartment in Hartford, yelling, “WHAT IN THE – HOW IS – HOW CAN – TH – WH – I – ” (etc.).]

I can comfortably say that there is not one step of that journey that I can visualize once we get on the bus that leaves Kaski.  Aamaa has never even been to Kathmandu.  The furthest reaches of my mind cannot conjure what she will think of JFK airport.

At my Williams talk, an audience member asked if it is “lonely” to live in the ambiguous territory between two incongruous worlds.  My answer was yes.  But also that I was in that between place before I ever left home: uncomfortable, questioning. This bridging is a rare gift I didn’t earn, but each year, I gain more perspective on the importance of staying uncomfortable, especially if you don’t have to.  Bridging keeps you malleable.  When you have to reconcile competing
worlds, you see how quickly things become stuck, how easily even small power becomes narrow-mindedness and false complacency disguised as expertise or experience.  I have been thinking about this a lot.

In my final blog entry last summer, I wrote about visiting a mosque in Kazakhstan, having been mostly isolated from the news for two months, and how I wondered that the most urgent fixations in one place are completely irrelevant someplace else.  I have the same feeling now as I shift back in to the part of my life where my own obsessions in the U.S. are passing trivialities.  If I stayed in one location, they would become deeper and more rigid.  But I have been given this lucky between.  It is rice-planting season, and we hope the rains will be full.  But we won’t know until the sky breaks, so all we can do is prepare seedlings and roll up our trousers.

Ready for action, y’all.

*

P.S. School teachers starting dental programs? Fo’ shizzle.  I would love to hear what all of you out there think about the presentation I gave at UCSF’s Global Oral Health Symposium last March (beginning here at 54:30). It focuses on human rights and uprooting academy-based (*cough, elitist*) approaches to solving health care disparities in developing countries.

Wanderlust, with “Trespassing!”

 

So the other day, a friend posted a Luftansa ad on Facebook with the caption, “this is the Nepal I love!” The post popped up in my feed, although it had nothing to do with me.

I clicked on it. The ad follows a Nepali fashion designer from New York back to Nepal as part of a “wanderlust” ad series by the airline. She goes to familiar places in Kathmandu, and then poses in front of the Annapurna mountains. And then, she eats a meal with some women who start to look very familiar – so familiar that I don’t recognize them in this context. And then, a teenage boy runs off of the roof of a house. His feet patter over the corrugated tin over our kitchen, which I had installed last summer to fix a leak over our cooking fire.

THAT’S MY HOUSE!!!! I start yelling. Luftansa decided to make an ad about wanderlust, and out of the ENTIRE GLOBE, they picked MY HOUSE IN NEPAL!!! I watch again. You can see Aamaa sitting right there on the porch with a white towel on her head. Have a look for yourself:

The colors of home – LUFTHANSA?!  I don’t think so!  Aamaa and Bishnu and I painted those colors!!  As my friend Bess says…trespassing!  You guys, this video has well over 3 million views.  Now, next question: who has a friend at Luftansa?  I think we should look in to a new corporate partner, no?

Go ahead and send your ideas my way…laura@jevaia.org.

The Power of Catching a Goat

 

At the end of each of my visits to Nepal, there is usually a collection of ridiculous, entertaining, and lovely things that haven’t found a home in any of my blog posts, but deserve to be known to the world. Herewith is enclosed this winter’s box of treasures.

1. Grab Your Desire

Signage is a very reliable source of amusement in Nepal. This is definitively the most awkward hotel welcome sign ever, surpassing even Hotel Touch Nepal, a winning entry from last summer. And yes, the hotel is actually shaped like an octagon, which under the circumstances I assess to be both logical and insane.

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2. All the Religions at the Same Time

Because Santa suit and Nepali pop song and traditional (Tamang?) dress.  This is how we do the Christmas street fair, y’all.

3. The Power of Power

For the entire decade and a half I’ve spent in Nepal, there’s been an ever-increasing amount of load shedding due to lack of electricity. The flashlight and solar power industries are enormous; our own office has $2,000 worth of back up battery power just so we can keep the lights and computers on. Everybody simply takes scheduled power outages to be a fact of life, familiar as rush hour traffic–in the winter when hydropower is lowest, load shedding lasts for up to 16 hours a day.

So apparently, just this fall, a new minister was appointed to the Energy Department, and revealed that the load shedding problem is, well, entirely due to collusion between the government and the energy industries. ENTIRELY.  Therefore, he simply declared load shedding to be over. After fifteen years, the lights went back on, and that was the end of it. I am telling you, there wasn’t more than 5 hours of load shedding this whole month, in the dead of winter.

I asked my friends why everyone isn’t absolutely up in arms about this. The answer was simple: everyone’s just glad the lights are back on. And besides, if anyone gets annoyed, they will probably be turned off again.

4. KP’s Dental Technician Henna Tattoo 

On the closing day of our university screening program, we discussed lessons learned, watched a slideshow of our week, and traded contact information. I had asked our technician Anita to bring some henna, and I did henna tattoos as people filtered out. Our technician KP demanded to have one placed on his chest, so obviously, he got K.P. and a tooth. His biggest UCSF fan, Helen, approved.

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5. The Power of Catching a Goat

My last morning in Kaski I got up and, as per routine, wandered outside to brush my teeth. As I was puttering around in the yard and splashing freezing water on to my face, I looked up to the terrace behind the house to see our 11 year old neighbor Amrit creeping up behind his goats, trying to catch and tether them to their posts, while muttering in a sinister tone: “DON’T UNDERESTIMATE THE POWER OF CATCHING A GOAT.” He would pounce just as a goat slipped through his hands and clomped off a yard or two away before losing interest and lazily looking around for something to chew on. Then Amrit would creep again, intoning, with intense focus: Don’t underestimate the power of catching a goat.

I highly recommend this as idle morning entertainment while brushing one’s teeth.

When I woke up the next day in Pokhara thinking about Amrit and started giggling hysterically in bed, Aidan and Pascal explained that there’s an action hero called the Blue Cat Man, who apparently goes around saying, “Don’t underestimate the power of the NILO. BIRO. MAN.”  It’s like the power of power, but with blue cats.  I unfortunately didn’t take a picture of Amrit with a goat, so here’s me with a goat.  You want to catch a goat now too, don’t you?

6. Paragliders in the Mirror

On Saturday afternoon following the closing program of our screening camps, when our field staff left to go back home, I went for a run to clear my head. The paragliders who we often see sailing down from Sarangkot make their landings in various spots by the lake in the valley, and every now and then I happen upon them at the moment they float down to the ground. That afternoon, as they drifted out of the sky, they were perfectly mirrored by other paragliders rising to the surface edge of the lake. The paragliders came down and attached themselves to their own feet, like Peter Pan and finding his shadow.

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7. It's My Shit

During their week of clinic audits and past patient assessments, Bethy and Keri came to spend a day in Kaskikot, and in the evening, we got to singing with Grandma. Thanks to Keri’s choice to blast “Holla Back” off her laptop, we ended up teaching Grandma to say, “It’s my shit,” and I did post a link to this before, but I am embedding it here because when you watch Grandma declaring that her shit is hers and not to be messed with, you will see why this is an absolutely brilliant thing to have happened.

8. The Prime Minister on a Tractor

The other night I looked up to see an evening news broadcast of Nepal’s Prime Minister inaugurating this tractor. He is covered in celebratory marigold malas far past the tops of his ears, making it hard to achieve either neck rotation or peripheral vision. In the TV broadcast, the gathered audience shuffles tenuously along on the muddy ledge around the paddy, clapping admiringly as the Prime Minister drives the tractor for about a full minute on the evening news, with no background commentary or voiceover whatsoever from the news anchors.  He stops and disembarks, and then the segment ends, while I squeal and point at the TV, my dinner forgotten on my plate, and the rest of the family is going…”What?” I present you the photo that was published in the Himalayan Times, with its caption.

I mean, What?

Prime Minister Pushpa Kamal Dahal plants rice in a field using a modern tractor during the inauguration of the Super Zone programme under the Agriculture Modernisation project, in Baniyani VDC of Jhapa district, on Tuesday, January 3, 2017. Photo: PM Secretariat

Prime Minister Pushpa Kamal Dahal plants rice in a field using a modern tractor during the inauguration of the Super Zone programme under the Agriculture Modernisation project, in Baniyani VDC of Jhapa district, on Tuesday, January 3, 2017. Photo: PM Secretariat

8. The Power of The Stage

Our sweet Pascal is 11.  He is named for the little boy in The Red Balloon who makes a strange and magical friend that leads him to see the world.  While Aidan is our Joker, Pascal is serious and perceptive.  He and I have always had the bond of The Observer, that sensitive creature who is perpetually catching up with the world on the outside, but seeing a little more than the next guy on the inside.  One night during this year’s holiday street festival in Pokhara, Pascal came to the hotel to find me and we spent some time walking around in the crowd.  We came upon a stage where kids where dancing until the scheduled performers came out.  Pascal paused a moment, and then jumped up and…he’s on the back left in the striped shirt.

9. These extremely uncomfortable mannequins in Kathmandu Mall.

Why, world? Why? Who approved this?

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The Ritual of Goodbye

 

I decided to take the jungle path up to Kaski, which I normally travel multiple times during any visit, but haven’t been up or down yet during this hectic winter. I set off late and as I climbed up, the scramble of things fell away and I was alone on the stone path.  Where there is time to climb and think.

It’s been a few years since the forest was cut here (for grass, firewood) so the way is lush and clustered with greenery.  I always wear flip flops and the contours of the rocks feel close under my feet, even in winter.  At intervals, I came upon dustings of red powder laying bright on the rocks, a trail I suspected had been left by a recent funeral procession headed in the other direction down to the river.  Midway up the path there is a natural spring that has been organized with laid stones, and one large flat rock with a groove in the middle serves as a ledge channeling a steady stream of water for drinking. When I come this way with the kids, they cup their hands under the trickle and funnel the water between their lips, like something out of the Secret Garden. The spring always feels like a sacred place, a steady tributary of water that started who knows where, up high in the mountains, probably, and falls there at our feet as we pass.

As I made my way up from the valley to the ridge, I had that granular awareness of time passing behind me, and it seemed so strange that at any moment I was on one stone, and then I would be on the next one, and just that way the whole path would be behind me and I would be up in Kaski, the secret water tap and everything far below where I’d just been.

img_1031By the time I climbed up the last step to the ridge top, I was a combination of chilly and sweaty in the January dusk. I walked the spine of the ridge, which curves along our cubby of village as if along the top row of a stadium. Little Narayan caught sight of me up along the ridgetop, and yelled out from way down in the first row where he was visiting a neighbor, LAURA DIDIIIIIIIIIIIIIIIIIII!!!!! before launching in to a sprint and leaping up over terraces to come walk the last bit of the way by my side. We made a right turn at our row in the top section of the stadium, and strolled out to the house sitting in the wings, where the fire was lit and Aamaa and Hadjur Aamaa were waiting.

We had some popcorn and hot tea as sunset approached. Narayan’s brother Amrit came over and in the yard we practiced taekwondo and played chungi, which is basically Nepali hackey sack using a ball of rubber bands, while Aamaa cried out at us to calm it down and I riled everyone up. Govinda dai came over and we sat with Aamaa in the kitchen while she made anadi paste, a rice dough with ghee that is healing for sore muscles and bones, and then we ate it and it made our hands sticky with ghee. Saano didi came over, and then Mahendra’s mother came over. We transferred to the big room with all the beds, and while our visitors took seats around the room to hang out, I jumped under the blankets with Hadjur Aamaa, and with us both lying down, my long limbs rested against the soft jumbled folds of her sari.

Aside from ritualized procedures and ceremonies – tikka-giving, astrology-reading, mala-making — goodbyes are wholly unfashionable around here. So what usually happens on my last day or last morning in Kaski is our closest neighbors come over to chat, but nobody talks about the fact that I am leaving, going to another world, and won’t be back for a long time. If we do, it is in the form of asking about the trajectory of my flight, how long I’ll be in the air, what they give us to eat during such a long journey, and whether or not it is colder where I’m going than where we are. We discuss what season it will be when I come back (summer), and what fieldwork we’ll all do together (millet planting and rice planting), and this leads us to reminisce about what a klutz I was when I first arrived, and how many things I know how to do now. At some point, people wander out mid-conversation. Because the course of events is set, both the leaving and the returning, and since there is nothing to be done, there is no point in becoming uncomfortable. I understand this ritual of goodbye, and have become grateful for it.

churning milkAfter most people had left, Govinda stayed while I churned milk so I could bring buttermilk to Pokhara tomorrow for the family. Govinda took photos of me, which is kind of nice because I don’t have many photos of myself since I’m always the one taking them – but then, people, he posted them on Facebook and two days later I would discover that this photo album is wildly more popular than anything I’ve ever posted of myself trying to be useful or worthy. What does it all mean?

When the milk was churned, Govinda dai left to go home and Aamaa and Hadjur Aamaa and I got ready for bed. It’s always been a nightly habit of mine to go out after everything is quiet and look at the stars, across the village stadium at Kali with her arms stretched out under her cloak, and study the positions of the constellations amassed around her. I usually walk out along the garden, and sometimes I climb halfway up the hill to the ridge and look back at the house with its golden porch light, a warm square in the broad, cold darkness. Even when I am far away from Kaski, I often feel my self located there, outside in the silence, looking back at the still, lit house in its expansive darkness. That spot is a place of gratitude and wonder, of tiny-ness and huge-ness at the same time: my little self, with coordinates in the galaxy.

It was another January night, clear and chilly, the stars laid out overhead like dust. I went out to the yard to brush my teeth, and for whatever reason, instead of going out along the terrace, I stood in the square of light cast off the porch and looked out in to the dark. In the summer, the yard is hemmed in by towering corn stalks, but in January, there are no walls against the yawning night.  I stared out in to the blackness, past the edge of the yard, and all I could see was the outline of trees under the stars, and an opening in the blackness at the top of the hill where the path gives way to the ridge.

It occurred to me that in all this time, I’ve never looked at it this way. I studied the inscrutable night, brushed my teeth, and threw my eyes up to the sky for a moment to make sure Orien was where I expected him.  Then I went back in to the house, placed the wooden bar across the inside of the door, got under the warm covers, and drifted off to sleep, safe against the morning.

*

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The Put In The Museum Pants

Welcome, world, to the new year 2017.  In honor of this changing of the calendar, I decided to take on some good old Kaskikot cleaning-out-of-old-clothes-from-the-house.  Now in order for you to fully appreciate what this means in context, you must understand a few key points.

First, the clothes in question have been in rotation for anywhere from 2 to 14 years, and for the most part, they are only worn when I’m in Nepal.  Second, these garments are mainly used for activities such as chopping wood and hauling water and painting murals, and they are washed on rocks. Third, p1070133all of the family clothes are stuffed in to one large dresser with drawers that have been labeled with permanent marker by the kids (“Lora and Bishnu, Ama, Malika and Prem, Aidan and Pascl”) and the dresser is always so full you almost can’t open it, or close it, which is why every time I get the Lora and Bishnu drawer open and then shove it almost shut, Aamaa yelps out from across the room and chides me for leaving one inch of air space that will look irresistible to a mouse seeking fluffy shelter from life.

Next you must understand that nobody throws anything away, ever, under any circumstances, because it was once useful, might again be useful, is nicely made, contains a wrapper or other information that might be needed for future reference, or just because I don’t know let’s just keep it here wedged between the roof beams because we have roof beams.

And finally, since I am away for 5 to 10 months at a time, partway through, Aamaa religiously takes out the nicely stacked and folded system I’ve left behind to air out everyone’s clothes in the sun.  They are then returned to their airless purgatory in maximum disarray.

It is also notable that at any given time, most people in the household cannot locate the particular piece of clothing they wish to wear.  I spend most of my time at home either trying to open the Lora and Bishnu drawer, trying to close the drawer, or looking under piles for something while Aamaa cries out, “No matter how big the house gets, it just fills up with things and then we can’t find anything!”  FYI this is a two-room mud plaster house with a kitchen and attic, which was once expanded from a one-room mud plaster house with a kitchen and attic, but that’s the EXACT SAME THING my mom says about our large suburban abode in Bethesda.  So you can put that last point in to your “Deep thoughts on human life” file and stick it between the roof beams for future reference.

In any case, on Dec. 31, 2016, I made a decision, people.  Grandma was sunning in the yard while Aamaa tended to the buffalo, Govinda’s kids were over, an attempt to fold and restore clothes to the Lora drawer with Sulochana’s help was going nowhere, and in a fit of courage I committed to assigning a pile of my best clothes to mattress material.  (I mean it, if you think anything ever gets thrown out, let’s talk about used-up pens and “good” empty cardboard boxes before we start wasting perfectly good 14 year old clothes.)  I handed my camera over to Sudir, and he and Sulo stationed themselves to document these items for posterity.

Now then, with no further ado, I present to you the parade of Useful and Sentimental Clothes.

Item 1: The Mural Surulwar

Mural, White Paint - Me

The very first time I came to Kaskikot, all the way back in October 2002, the volunteer agency took me to a tailor and I had two outfits sewn.  I wore them constantly during my first two years, including through the painting of two murals at Sada Shiva Primary.  One top frayed out of existence a few years ago, but these two outfits are mostly still in circulation for both sentimental and practical reasons: they became my go-to outfits for mural painting.  This pair of pants, however, is difficult to wear in pretty much all circumstances.  Bye bye special beige painting surulwar.  We’ve walked so many places together and you’ve had so many kids I love on your lap.

Item 2: The Elastic Bathing Lungi

Fortunately I don’t have a “before” photo of the bathing lungi.  But it too is a lifer: it has been bathed in for 14 years.  In fact, I think I inherited it from another volunteer that was leaving when I arrived in 2002.  Suffice to say that this little number is no longer appropriate for bathing, or really for anything except becoming a mattress cover.

Item 3: The Red Kurta I Stole From Bishnu

Round about my third visit, I started to wise up a little on style.  Anecdotal evidence suggests that when Nepali tailors sew outfits for white people, they just go huge and hope for the best.  We look like Yetis, but at least we can get in to these outfits.  As I became more interested in a fashion choice that wasn’t a mumu, Bishnu’s loosest outfits were large enough for me to get in to as long as I didn’t breathe too much.  This red top was my favorite and eventually I had it let out a little around the lungs.  When I wore it with some red pants I found, I felt like a princess, but then someone made the red pants in to a mattress, so I reverted to wearing it with the beige Mural Surulwar.  It then became covered in paint, and torn, but it’s had a great life on multiple Spero-Subedi women.

Item 4: The Put In The Museum Pants

I got these jeans for $10 at a discount mall in college, and they were my Nepal jeans for about 10 years.  They got patched in the crotch, the butt, around the ankles and in various locations where they caught on things here and there.  I took a lot of crap for wearing these pants, which Prem had coined the “Put In The Museum Pants” for quite a few years before I stopped wearing them.  I discovered them at the bottom of the Lora and Bishnu drawer, and I’m glad nobody throws things out here, because it would be terrible to think of these trusty pants in a ditch somewhere.  Unfortunately they do not fully qualify as pants any more at this point; they evolved closer to the mattress stage while still on me.  Since I’ve clearly enjoyed sitting on them quite a bit, I’m glad someone will have a nice night’s rest on them…like a museum, but lying down.

They will be next to this AAU Taekwondo Nationals t-shirt that I got in 2008; it had a rougher life once it moved continents.

Item 5: This one’s not my fault.

This is a kurta surulwar that belonged to Bishnu about 10 million years ago.  I was able to convince Aamaa that nobody is going to wear it again ever for the entire future of the planet until the sun explodes.  I tried to lower my arms for these photos but to no avail because the outfit was sewn with inexplicably tiny sleeves and indefensibly large and poofy pants for someone 1/2 my size.  Thank you for just being you, outfit that makes no sense.  You inspire us all.

Item 6: The One I Couldn’t Bear to Actually Give Up

Oct. '03

This is the other kurta surulwaar I had sewn for my first ever visit to Kaskikot.  I wore it constantly and the material appears to be more durable than bulletproof kevlar. I have photos of myself carrying grass in this purple kurta, teaching in this purple kurta, holding a cat in this purple kurta, going to a dental clinic in this kurta, and giving Mom and Aamaa a joint foot massage while wearing this purple kurta when my parents first visited 2003.  Purple became my symbolic color, and often when I receive gifts in Kaskikot they are purple if they are not edible.  The kurta, as you can plainly see, evolved in to my primary mural painting smock, and hasn’t been used in quite a while. But I still wear the dark purple pants around the house even though the crotch is ripped (YES, I have leggings inside, jeez) because the thick purple material is still warm and soft and because the Yeti sizing is perfect for lounging. I decided it was ok to hang on to these much-travelled and much-loved pieces of history a bit longer.  Maybe my great-grandkids will get a kick out of this getup.

So after we had finished modeling the upcoming mattress, we shut the dresser drawer, Sulo did my hair with a complicated formula of braids and safety pins, and we had a dance party with Grandma.

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Happy New Year!

No wait…one more for the road.

Cause I’m keeping the purple one.

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Tihar, Festival of Lights, 2003

 

 

 

 

Evidence. FINALLY.

 

Sada Shiva Primary, 2004

Sada Shiva Primary, 2004

The very first oral health program I organized with Govinda, at Sada Shiva Primary, was in the spring of 2004.

We launched the Kaski Oral Health Care Project in 2006.  Over the years we’ve gradually refined our approach, added in pieces that address culture and product availability, vastly improved our integration with the government and with schools, and pushed the standard of care in our clinics as best we know how.  We have our own unique sanitation protocol that I put together doing my own research. We’ve learned not to take the status quo for granted, and to seek more information about what is legitimately possible in low-resource settings. We’ve learned to recognize complacency: I’ve had to get comfortable with being told things should be done one way, and then seeing with my own eyes they should be done a different way.  But up until now, we’ve basically been doing this on our own.  We try to do annual medical audits of our clinics with local dentists, but our clinics are, increasingly, unique entities.  As a result, there isn’t really a solid barometer of care in Nepal, because we set our own standards – OR internationally, because, well, we’re in rural Nepal.

In 10 years, I’ve never had foreign dental professionals come to witness, much less rigorously assess the care provided by our clinicians.  For that reason, the most promising part of this whole collaboration was what came this week: clinic audits and evaluation of patients who have had fillings done in our clinics some time in the last eight years.

From a human rights standpoint, this is an incredible opportunity for research.  JOHC technicians are nontraditional health care providers offering a technical form of medicine that is totally absent in rural Nepal.  If we can get hard data showing that their treatments are safe and effective, we have a rigorous foundation for arguing that similar clinics should be incorporated in all 3,000 of Nepal’s health posts.  This kind of data isn’t that easy to get, because you’d have to search pretty far to find other patients who were treated 5 or 7 years ago by rural dental technicians in real, remote contexts, rather than by visiting doctors doing controlled research.  In fact, I don’t where you’d find that at all.

With that in mind, I am thrilled to say that, in addition to visiting four of our clinics to provide general evaluations and technician feedback, Dr. Keri and Dr. Bethy screened over sixty past patients.  Both of them use glass ionomer extensively in their own practices; Keri is a pediatric dentist in Connecticut and Bethy is currently doing a PhD incorporating similar techniques in to schools in Cambodia. So these two ladies are like space aliens from another dimension…they know SO. MANY. THINGS.  We invited the past patients for assessment and then the result was out of our hands.  I was excited and nervous.

Their evaluation focused only on glass ionomer fillings, taking close up photos that show how the treatments have held up.  The fillings were anywhere from a few months to 6 years old.  Here’s the screening in Sarangkot, our longest-running clinic:

 

Bethy and Keri were able to screen past patients in three different locations, documenting outcomes from of three out of six of our technicians. What they found is that these treatments have provided objectively, measurably positive health benefits.

Let’s say that again.

What they found is that our rural dental technicians, who are Nepali people working locally in their own villages to offer the only sustainable rural dental care in Nepal, have provided objectively, measurably positive health benefits for their patients.

In fact, given the conditions in which they are working, they appear to be getting EXCELLENT results.  And with the photo documentation that we have, it will be possible to do a fairly in-depth look at exactly what that means–hopefully, something publishable.

There are also ways these outcomes can be improved, and this process allowed the doctors to pinpoint some very specific methods for how.  For example, our technicians should be provided with additional hand instruments that will allow them to improve the cleaning of the tooth before the filling is placed, so that it will last better.

We did clinic audits and past patient screenings in Bharat Pokhari, Sarangkot, and Salyan.  We also went to see a school seminar in Rupakot.  So over the course of the week, Bethy and Keri got to work intensively with all of our technicians, even if getting to every clinic was not possible.  They gave us feedback on supplies and setup that can continue raising the standard of safety and quality in our clinics, which all use the same supplies, so we can generalize that feedback even to the clinics they weren’t able to reach on this visit. We’ll also be starting a Facebook page for technicians to continue learning from Bethy and Keri.

Every night, we’d come home from one jeep ride or another, and these two would still talking about ideas to support our technicians and strengthen outreach to schools. They just KEPT THINKING OF THINGS, and in the morning I’d wake up to find that they had gone to have coffee, where they were still talking about instruments and procedures and lights and glasses and training videos and possible articles to write.  It was INCREDIBLE.

Also…it was really fun.

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Real Work in the ‘Hood

 

After our week of screenings in Puranchaur and Hansapur, I took our university teams up to Kaskikot. We didn’t arrive in until late on Sunday night, after visiting our Bharat Pokhari clinic during the day.  Everybody stayed in the hotel behind the house, but most people came down to hang with me and Aamaa and Hadjur Aamaa for a while.  We had tea, chilled in the kitchen, and of course I put some Henna on Neha and Justin.

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The next morning, we said bye to Karen and the Berkeley/UCSF crew.  It’s been so special hosting these guys, and we’ve all learned so much from them.  First of all, we had an immersion week in the science of oral health and nutrition, and also in research and evaluation.  But it was also so invigorating for our field teams to get to work with Dr. Karen, Dr. Madhurima, and the students they brought, and I can’t wait to see all of these guys later this spring out in California!

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Keri and Bethy are sticking around for another week, which began with a trip to Sarangkot to screen past patients and do a clinic audit, which I’ll write about in another post.  We came back to Kaskikot on Monday night so that after this marathon week, we’d have the next day to just hang out.  In the evening, we lay around in bed exchanging songs with Hadjur Aamaa.  She wanted to see some dancing, and Keri turns out to have an amazing workout mix on her laptop, so that kept Hadjur Aamaa solidly entertained for quite a while.  In exchange, she allowed us to teach her some lyrics from “Holla Back.”  This is Hadjur Aamaa learning to declare, “It’s my shit.” (Video credit: Keri.)

First thing in the morning, I put Bethy and Keri to work churning milk, while Aamaa bustled back and forth past us over and over again, saying we were going to ruin it, which was a possibility, and I replied that everything was going to work out just fine, the foreigner way.  Which basically gave Keri and Bethy the full experience of my life.

Next, of course, I commandeered the dentists carry to water in baskets, which was well worth it just for this fantastic piece of documentation.

What?  We needed a lot of water.

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We hiked up to the Kalika temple and had a photo shoot.  I’m not even gonna explain how this happened…Bethy was in the New Zealand military and has superpowers.  I just had a good photographer named Keri.

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We came home and spent a couple hours in the yard with Aamaa and Hadjur Aamaa shucking corn.  TBT to the time my family came to visit in 2004, and we shucked corn in the yard:

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Shuckin' Corn

Tomorrow we’re on to a school seminar in Rupakot, and then Salyan for another clinic audit.  But this was a pretty swell stop, in my unbiased opinion.

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Too Much Good

 

The village of Hansapur is adjacent to Rupakot, one of the villages where we’re nearing the end of our two-year program and preparing to hand over the clinic later this spring.   We’d asked Dr. Madhurima if she would conduct her study on mother/child oral health and nutrition in one of our non-working areas to allow for comparison.  It’s an anecdotal comparison of course, because Hansapur and Puranchaur have many differences besides the presence of JOHC in the health post and schools, but it’s something.

Our morning once again consisted of a bouncy bus ride, singing, and this time an extra jeep carrying some folks from another health agency joining us today.  Partway along, Helen had the img_4824idea to jump in to the back of the jeep, and she was soon joined by our Sindure technician Jagat, our Salyan team leader Nar Bahadur, and me. We bobbed along with the fresh air and hills rolling by and the dust billowing up behind us on the dry winter road.

Since we don’t have a clinic in Hansapur, today’s program was held in a schoolyard.  It was challenging getting this screening day set up because we didn’t already have a network of teachers and an existing relationship with the community to help with turnout. But with the high attendance in Puranchaur, we felt a little less pressure, and just went hoping for the best.

So, like, about 350 people showed up.  It was INSANE.

This was the kind of success that, in Nepalenglish, we call “too much good.” A little less good might have been gooder.  The technicians had no time to pee, and Dr. Bethy and Dr. Keri ended up treating patients all day instead of mentoring, because there were just so many people to get through. When we finished the last patient, it was night time.

But of course the high attendance had a many up sides too.  First it was awesome for Madhurima’s study, which we were concerned about.  And a few hundred people also got treatment and fluoride varnish from local technicians.  We observed that childhood oral disease in Hansapur was significantly worse than in Puranchaur, and while that can’t be attributed off-hand to our school brushing programs and outreach in Puranchaur over the last two years, it doesn’t hurt to know.

But the thing about this day that I most appreciated was that it only took until about 1pm before Nirmala, the local organizer who’d helped us get setup, sat down with Aamod and me and announced that she feels our full program is needed in Hanspaur.

thumb_img_1144_1024This represents a major turn of tides for us. We’ve always had to do a lot of running around to create demand in the villages where we start. Then we keep at it for two years, hoping that at the end, the community and leaders will still be convinced enough to make good on promised long-term funding. We’re now realizing that we’ve developed enough infrastructure to provoke interest by just showing up and doing our stuff.

So our plan from here on out is to start only in villages that pay the technicians locally from day one. January is the month where villages throughout Nepal submit next year’s budget to the district government. For the first time, we’re positioned to invite places like Hansapur to co-invest in health post dental clinics from the start. In other words, this epic day of screening and treatment doubled as a 1-day free trial, and now local officials can sit and decide whether to allocate funds in a long-term solution for which we’ll provide the architecture, training, set-up and supervision–so that it comes out right, reflecting everything we’ve learned in the last 10 years.

Are you keeping up here? That was day three.

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Over the Mountain and Up to the Clinic

 

Yesterday morning all 30 of us piled in to a bus to head out to our first day of screening in Puranchaur. I kept being worried that someone on our field staff would bail out, get a flat tire, have a sick buffalo, or need to attend a last-minute puja at an uncle’s house. But everyone made it on to the bus. And it took very little time before bus songs began, complete with Live Traditional Dance By Dental Technician.

Thank goodness I have 12 years of Race to the Rock under my belt. I knew to have a map of our planned camp flow, and I hoped that, as we’d been assured, the needed chairs and tables were already at the Health Post waiting for us. I’d printed out this camp-layout-2high-tech map for everyone in their welcome packets, and I brought an extra copy of the map with me since I knew most people would leave their welcome packets at the hotel, and this series of actions allowed me to answer most questions in either language from any one of 30+ people with: “Ah. Have a look at the map! Oh that’s okay. I put a copy of the map over there. It will answer all your questions.” Tricky, right?

We are aiming to have 300 mother/child pairs for Madhurima to screen in the next three days. That is a lot of people to mobilize in a rural area where people are busy cutting firewood during this season, and especially when you consider Puranchaur already has weekly dental services available, plus we’ve done outreach in schools already. We’re hoping that will work to our advantage, and that the teachers assigned in each school to run the brushing programs will bring students and mothers. But it’s also exam time, so we knew things would be slow till mid-morning. Once everything was set up, there was that familiar lull…would anything happen?

…Anything?

Then suddenly we looked out and saw this line of primary school kids in their uniforms winding our way over the hills towards us. If this isn’t the cutest thing you’ve seen related to dental care outreach programs in mountainous regions, you have no heart.

I want to explain how we organized this project using a human-rights design, because it seems obvious, but actually, a lot of these details are rarely prioritized. What we care about with JOHC is the development of dignified, sustainable, high-quality health care for rural Nepali people. It was important to me to set up this collaboration in a way that promoted the development of local services, which meant not only studying interventions or issues in the abstract, or providing a transient benefit to participants in a study, but building the manifest capacity of local providers and institutions.

Fortunately, although JOHC is small it is mighty, because we have those providers and are already working with all the schools, the local government, and the local img_4484Health Post in Puranchaur. The involvement of our team leaders and clinic staff in this project was a great development opportunity for them – and therefore the communities they work in – and as long as consciously nurture it, that benefit occurs regardless of the outcome of the research.

We were also able to set up this collaboration as an opportunity to strengthen and test our community relationships. Our preparation involved a great deal of mobilization, largely done by our team leader in Puranchaur, who is himself a local resident. We’ll still be in Puranchaur when the week is over, so we’re accountable and vulnerable to the way in which the program impacts the community and its power structures. Which is as it should be. In short, the project is about Puranchaur and the other villages where our teams work, not about us, and that’s what I care about.

Of course, we still had our breaths held all morning. We had kids, but would we get mothers? But as the day went on, the pace picked up. Things got so packed in the clinic upstairs, where our technicians were providing their usual treatments plus the new fluoride and silver fluoride treatments, that by the second day, we needed to move to a large training hall. On the second day, as word got out, we got even more people – about 140. Bethy and Keri were able to provide intensive oversight to our technicians as they worked; our team leaders were collaborating with the UCal students to conduct surveys, help with dental exams, and provide the same oral health and brushing instruction they do already in their home villages. On the ride home that evening, our team leader Kasev, who had been conducting interviews with mothers, said that many participants referenced the school brushing programs when talking about their health practices.  It was as awesome a day as we’d have dared to hope for.

Tomorrow we are off to Hansapur, a non-working area where we had to apply our best strategies to get the word out.  It’s a great chance to get some anecdotal evaluation of differences between an area where we work, and one where we haven’t yet.  Let’s hope we get as good a response as we did today!

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