Gaurab the Bear

Recently, Bethy was in Thailand and discovered that someone there has been making teddy bears with a full set of teeth.

In my life, this is a very interesting and exciting finding.

Bethy decided to order some teddy bears with teeth for health centers in Cambodia that are running an early childhood hood oral health program, and I figured I would bring a teddy bear over to Nepal. It was fairly simple. In brainstorming the idea, we got to thinking about the enormous contribution that Jevaia’s Education Field Officer Gaurab has made in our organization, beginning long before we had a name. Gaurab was our first Clinic Assistant in our first clinic in Kaskikot. He volunteered for years as a teenager in school seminars, teaching kids about about oral health. He became one of our field officers in 2015 and has walked literally countless miles, up and down hills, in the rain, after dark, and in just about every crazy situation possible to promote oral health in schools in Nepal.

We decided our first teddy bear with teeth should obviously be named Gaurab.

When I arrived recently in Cambodia, Gaurab the Bear had completed the first leg of his journey, from Thailand to Cambodia. He came with frens.

We were so excited to meet him!

We hung out in Cambodia for a while, and then Gaurab’s frens said goodbye

And we left for the airport.

We took a tuk tuk.

Gaurab seemed to like the airport

and he really blended in with all the other travelers.

Especially while waiting for his flight.

He settled in, clutching his ticket to Kathmandu

And we enjoyed perusing very expensive jewelry that isn’t really less expensive even though it’s Duty Free, in Kuala Lumpur.

Honestly we were pretty tired by the time we finally arrived in Kathmandu and Gaurab tried to be patient with the visa process but he was ready for a nap.

The next day, refreshed for our flight to Pokhara, we made some NEW Frens in the airport!

You can imagine Gaurab’s anticipation on the flight west…

And finally, upon arrival we were greeted by some real big fans.

Finally, after meeting the rest of the team, Muna and Rajendra,

 

 

 

 

 

 

 

Gaurab was united in the office with Gaurab!

Welcome to Nepal Gaurab!!

Worry For My Sons

I’ve just come back from my third visit to Cambodia, and each time I expect to write about it. I’m no qualified scholar of Cambodian history, but I spent a short time working with Cambodian refugees in Hartford and two months researching the Extraordinary Chambers, or ECCC, the war crimes tribunal created to adjudicate the crimes of the Khmer Rouge.

In August 2017, I visited the Tuol Sleng Genocide Museum in Phnom Penh, where I filled in the mental scaffolding I’d established by standing outside of empty torture rooms and running my eyes over thousands and thousands and thousands of names, knowing they would vanish from my memory. 15,000 people were imprisoned and killed at Tuol Sleng, which had once been a high school. I lit incense in a somber memorial room at the end that is filled with skulls.

Sometimes it seems that the cruelties of history are mostly remembered through their persistent pain, despite our best efforts to know them through redemption.

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“What do you think of Cambodian politics?” asked my tuk tuk driver today, on the way to the airport.

“…What do you think?” I replied carefully.

“No good,” said the driver. “Not much has changed.”

Motorbikes and trucks and cars and luxury sedans jockeyed for space on the highway, pressing in on the open sides of our tuk-tuk, where I had my leg through the strap of my bag after twice having items snatched off of me by passing motorists. It seems hard to argue that not much has changed. When Phnom Penh was reclaimed from the Khmer Rouge in 1979 after four years of destruction and enslavement, the rubbled city no longer had electricity or plumbing or safe water or schools or working telephones; the use of money had been abolished. Nearly a quarter of the Cambodian population and most of the educated class had been slaughtered. There were at total of seven lawyers left in the whole country to rebuild the government. Working off my not-particularly-relevant experience of what it’s like trying to develop infrastructure in Nepal, I find it absolutely astounding what Cambodia has rebuilt in just four decades, albeit under an authoritarian regime.

I guessed my tuk-tuk driver to be in his early fifties, old enough to have been alive during the genocide. I wondered what he wanted to tell me about.

“Where were you during the war?” I asked.

“In the province,” he said. “We planted rice, you know? Planting all day. All the kids slept together in a large area, on a rough surface. My skin got very irritated on my whole body. We had no rice to eat. We only ate porridge.”

“How long did you do that for?”

“Two years,” he said. “I was eight.”

I learned that the driver had one sister and five brothers, and I wanted to ask how they had fared, but didn’t know if I should. Many children whose stories started this way lost their entire families under the Khmer Rouge, sometimes before their eyes.

“What do you think is the biggest problem for Cambodia now?” I asked instead.

“Education,” the driver stated firmly. I learned that he had been able to pick up his studies again in 1982. That Cambodia has struggled to rebuild its education system is no wonder. In 1979, there were so few intellectuals left alive that a former math teacher, Chan Ven, was put in charge of rebuilding the Ministry of Education. The three-decade old United Nations, with its dominant American, British and Chinese powers, opposed the new Cambodian government because it was backed by the Vietnamese. So after receiving more American bombs on its soil during the Vietnam war than Japan received during World War II–an act that won Henry Kissinger the Nobel Peace Prize–a traumatized Cambodian populace was left to prosecute war crimes, reconstruct the government, and reestablish basic institutions without the help of international human rights bodies. During the Cold War, the Hun Sen military regime that liberated Cambodia from the Khmer Rouge was systematically and repeatedly denied U.N. support, which was deferred instead to the Khmer Rouge in exile.  To this day, the regime continues to run the government and suppress opposition.

My tuk tuk driver took his gaze off the road and turned his head toward the side, maybe only because I was seated behind him, but it made it seem like he was looking out at the tall buildings around the highway. “My sons are studying law and engineering,” he said. “I worry about them.”

Last Saturday, a bunch of us took a long ride out to see the new Win-Win monument. The tower was recently built to commemorate the end of civil war in Cambodia in 1998, when outlying factions of the Khmer Rouge finally entered in to an agreement with the Hun Sen government, bringing about the end of decades of violence. The monument is built of intricately carved sandstone and polished granite, and in many places is still under construction even while throngs of mostly Cambodian visitors visit each day.

What most caught our attention, though, was a lengthy retelling of Cambodian history carved in to stone panels around the base of the monument. It starts before the genocide and continues for probably a quarter mile or more. The story is portrayed with a nationalistic fervor that is not subtle, and the monument also sits across the way from a large athletic complex being built for the 2020 ASEAN Games. It is clearly a display of political pride and might. One might say unvarnished propaganda. On the ride home, we found ourselves talking about the importance of uniting narratives in national identity.

But before we left, we trod through the entire narrative display panel by panel by panel, slowly watching sun change its shadows on the carved faces. One, near the beginning, captivated me for some time. It’s intimate brutalities are historically accurate.

“During the war,” said my tuk tuk driver as we reached the airport, “it was just me and my sister. We were separated from our parents. Then my mom had five more children after it was over.”

I expelled a sigh of relief. “So your family survived?”

“Yes,” said the driver. “Five more children!” he chuckled. “And I’m the eldest.” He stared at the road ahead, thinking a swirl of thoughts I couldn’t intuit. He seemed to want to discuss it with me during the thirty minutes we would know one another. “You have freedom in America,” he said, shaking his head. “I just…worry for my sons. And their education.”

“They sound very smart,” I replied. At the time, I assumed he was worried about affording his sons’ education, or about whether they would be successful in their pursuits, and maybe that is he that is what he meant. But it occurred to me later that, maybe not.

We arrived at the airport, and the driver dropped me off, and rode back in to the traffic.

*

Professional Ceiling Clouds

Finally getting around to publishing this post from the summer…enjoy 🙂

For the year and a half, we’ve been extremely lucky to be able to provide bi-annual professional development for our dental technicians and clinic assistants.  It has quickly become one of my favorite parts of our project.  Jevaia dental clinics deliver the Basic Package of Oral Care, a collection of dental procedures that was designed in collaboration with the World Health Organization for limited-resources settings.  The BPOC was developed by Europeans, and it has mostly been used in developing world settings as aid or transient care.

Since we train local dental technicians to provide the BPOC in Health Posts instead of temporary camps or outreach programs, we’ve had the chance think about applying it as a sustained primary health care strategy–especially since we started working with Berkeley, Dr. Bethy and Dr. Keri and other collaborators in 2016.  I suppose that kind of thinking is one difference between aid, or any kind of temporary relief, and human rights, which entitles people to a consistent standard of health care.

Our past three professional development workshops have focused on the use of Silver Diamine Fluoride; infection control tailored to rural Health Posts; and treatment planning (one thing about a stable primary care provider is: they can actually plan!).  This summer, Dr. Bethy is teaching our professional development on school-based treatment planning, so we can shift to a more systematic school-based oral health care model with local dental technicians.

Dental technicians in JOHC already conduct monthly school seminars to do school-based screening and treatment for children and parents.  We call these “seminars” rather than “camps” because they are run by a local provider and they help connect people with the Health Post dental clinic. Unlike most “camps,” seminars don’t aim to treat as many teeth as possible in the shortest time, but to build relationships with the technician and raise public support for a government dental clinic and community outreach programs.

Our 2018 summer professional development was seven days long for veteran technicians and ten days for new technicians. It kicked of with technicians and assistants examining photos of real ART fillings (like the kind they do) organizing them in to acceptable and unacceptable outcomes. Then the clinicians had to use the photos to diagnose why the unacceptable treatments had partly or fully failed, which lead to a review of practice technique. It was really gratifying to see how this impacted everyone’s thinking a few days later, when we were back in a school placing fillings.

Since the BPOC was originally conceptualized as crisis management, a challenge of our project establishing a quality of care standard in a stable primary care setting. At this year’s workshop Bethy helped introduce a competency framework.  During the three days of classroom work, our new technicians supervised old technicians in a “simulation seminar” where they had to demonstrate each technique using the competency checklist.  When we moved to the three-day school setting with live patients, new technicians were supervised through ten of each procedure and had to pass the competency checklist ten times.  Veteran technicians performed one of each technique under a doctor’s supervision and we used the completed checklists to award “competency certifications” that are valid for 18 months.  We even created a framework for technicians to review their competency certification every 1-2 years.

 

 

 

 

 

 

 

Overall, the workshop was meant to guide our clinical teams toward a more rigorously informed, holistic approach to school-based health care, where JOHC technicians work as members of the primary care system rather than visitors. The training emphasized taking time to slow down and connect with patients rather than blowing through a line at the door.  Dentistry can be scary and rather than jumping straight at a kid’s teeth, the intake leaves time to comfort frightened children and to learn about their lifestyle habits and disease risk factors. In turn that information is used to provide more complete and well-informed care, instead of just treating as many teeth as possible. It seems obvious, especially for primary care practice, but in reality that’s not usually how dentistry is done in our setting (or often, in general, if we’re being honest). As part of this, the clinical teams spent a good amount of time reviewing cariology (the biology of oral disease) which unlike the practicalities of how to mix cement and apply it properly, informs which techniques should be used when.  In other words, without adding in more high-technology interventions, we are focusing on more effective deployment of the conventional BPOC.

For me as a non-clinician, it’s super interesting to see how these minimally-invasive techniques can be used not only for emergency management of foregone problems, but for early intervention and prevention of disease in the whole child.  In all children, actually.  This same package of care can be used in service to population level public health needs where resources are a practical limitation, and yet there has been little focus on applying it that way. My dream is that one day it will be rural technicians and assistants presenting to academics at conferences on how they’ve adapted and improved these innovations to benefit their communities in the real world.

An incredible thing happened on the third day of our practice seminar in Kaskikot.  The school we chose is next door to the Health Post.  The third day was reserved for parents so that technicians could apply the training concepts to adult patients.  I was waiting out in the stairwell when suddenly I saw a face I could never forget: Nisha, one of the students I taught for a year at Sada Shiva Primary when she was in fourth grade, a million years ago.  It was with Nisha and her classmates that Govinda dai and I ran our first ever school oral health program back in 2004.  At the end of that day, we took a photo of all of us in front of the Kaskikot Health Post, which at that time was just one simple building that today is fully dedicated to our Dental Clinic.  Nisha had come to our seminar because her daughter is a student at the school where we were running the training in 2018–with five dental technicians, seven assistants, and an international expert in public health dentistry as trainer.



 

 

 

 

 

 

Finally, the icing on our professional development cake was a world-class makeover for the Kaskikot Clinic.  My friend Maelle who lives in Pokhara started an organization called We Art One that paints murals and does art programs in schools.  We asked We Art One to turn our Kaskikot Dental Clinic in to something bright and welcoming.  They took it next level, putting this exuberant mural on the outside and literally building a ceiling mobile inside for patients to gaze at while lying in the chair. It’s made from hand-cut wooden clouds that Maelle painted.

I know not every rural Health Post in the world can have clouds and rainbows hanging from the ceiling.  But I think they all should and I think we should try. The only reason we need is that every patient in the world is a person.  Those of us with choices would never choose health care in an unfriendly, cold or unwelcoming environment, especially for medical treatment that can be scary like dentistry. I don’t know why we seem to believe in some kind of false economy that suggests it’s not realistic to afford that dignity to everyone.  This beautiful artwork was not expensive or difficult; it was just a decision.  It mattered more than doing something else for some other purpose.

So that was our summer.  Two new clinics and nine veterans are open for business, if anyone out there needs an appointment!  Come visit us soon!

2004:

2018:

 

 

 

 

 

 

 

Airport Gymnastics

Bethy and I are on our way to Thailand to present at the International Association of Dental Research Conference in Da Nang, Vietnam.  We are on a panel about “Behavioral Science and Health Sciences,” me to present about Jevaia as a social justice project and Bethy to talk about a system she developed for school-based health care in Cambodia.  Between us, let’s call Bethy the scientist. She plans ahead. She calculates things such as time and has an external battery pack with every configuration of port imaginable and a rubberized exterior that could withstand a nuclear attack, and she brings it with her almost everywhere.  Bethy is a prepared and organized kind of person. I’m what we could call…the artist. I hit snooze 4 times and borrow chargers from nice people along the way. I don’t travel without chocolate.

We meet in Thailand, the mutual transit point on our respective journeys from Nepal and Cambodia to Vietnam.  The next afternoon, at Bethy’s urging we’ve arrived at the airport a solid two hours before our short international flight from Bangkok to Da Nang.  How planny of us. As we are checking in, the clerk asks us to display our visas for Vietnam.

We are both surprised.  Even the scientist! With our American and New Zeland passports, we thought we could purchase visas on arrival in Vietnam.  This is somewhat true, the airline agent tells us. However, there is a new process that requires visitors to submit an online application ahead of time and bring an electronic visa approval to immigration upon landing.  Without the approval, we aren’t allowed on plane.

Well then.  This is awkward.

The Airline Agent informs us politely that we have 47 minutes before check in closes.  I get my phone connected to the WiFi and start googling around for how to apply for a visa to Vietnam.  I find a website called Vietnam Visa Online (lovely name, quite to the point) that says this can be done with approval rushed to one hour, for a fee of only $500.

While I’m poking at my phone looking for a less pricey extortion option, Bethy assures the Airline Agent that we’ll definitely have no problem completing the required process in 47 minutes or less.  I tap madly at my phone screen, and we decide to go for a rush fee that’s only $100 and might or might not get us the visas in time. I click send. Bethy stalls with the Airline Agent. The check-in line shrinks, I hit refresh on my phone, and by now our window has diminished to 13 minutes.

…Tick tick tick…check in closes.

But not before Bethy casually softens the Airline Agent in to printing out a document that shows we arrived on time, and woos her in to walking us over to another desk where we can stare at my email waiting for the visa approval to arrive on the basis of our $100 rushfee. A new Airline Agent looks delighted that our problem has been moved over to her counter, where I set down my phone and Bethy and I peer deeply in to its icons.  We wait.  Airline Agent #2 waits.

An email!  Is it our visa approvals?  No. It’s a reply stating that due to the fact of today being Saturday, urgent processing isn’t possible.  However, we do have an attractive option to pay another $300 to get the visa approval today, or we can certainly wait in Thailand until Monday.

We kind of have no choice but to do the extra-special saturday rush fee, which has been specifically designed, after all, for suckers like us.  So we pay the fee, and then the screen freezes, and we can’t tell if we’ve paid $300 or not. I get an email saying that we can call an office in Vietnam with questions. But honestly, who has questions?   

Calling Vietnam would be a fine idea except that neither of us has phone cards that work in Thailand, so I ask Airline Agent #2 if she can call the Vietnam Visa Online from a land line.  She says the airline has no way to make international calls.  “But you’re an airline,” I point out. This doesn’t change anything, since apparently Asia Air actually cannot make an international call to a mysterious Visa processing office in Vietnam. I deduce this because eventually, Airline Agent #2 takes pity on us and gives us her personal cell phone.  We call Vietnam Visa Online and induct a fourth person in to our lair of chaos.

Mean time, I still can’t tell whether the payment has gone through on my credit card, and my credit card password isn’t working (or theoretically it’s possible I haven’t used it in a few months and I can’t remember it) so I can’t log in and check. For the next twenty minutes, the clock ticks down to our departure while I toggle between my phone and tablet trying to figure out if I’ve paid the fee, and Bethy toggles between Airline Agent #2 and the newly inducted lady from Vietnam Visa Online, whom we have to keep calling from the Airline Agent #2’s personal cell phone.  The voice in Vietnam talks us calmly and assuredly through various steps, which I tap out on my phone, as if we are diffusing a bomb.

Eventually, all three of us–Airline Agent #2 is all in now—are leaning anxiously over my phone, hitting refresh, waiting for the document with our visa approval to show up from the Helpful Voice in Vietnam.  Whose name turns out to be Selina.

Is it there?

How about now?

We may have to carry on our bags.

…Should we call again?

……Is it there yet?

……..How about now??

TADA!

The email arrives.  All three of us bounce up from my tablet screen and give a shout.  Airline Agent #2 triumphantly passes our boarding passes over the counter and we run to the gate.  I won’t see it until we’ve already arrived in Vietnam, but another email has popped up from Selina at Vietnam Visa Online.  It is highlighted in an alarming fluorescent yellow the color of a radioactive duck.

HAVE YOU RECIEVED YOUR VISA YET? IS EVERYTHING OKAY NOW? PLEASE ADVISE!

I write Selina back after we land in Da Nang.

We are here in Vietnam and everything is fine! I didn’t get your mail until we landed. Thank you for all your help today!

We’re aware that it would be responsible, at this stage, to be upset about the insane amount of money our visas just cost, but instead we are delighted with the exchanges of the day, the managing and wooing and reassuring and eventual co-conquership with strangers of our last-minute visas. In fact, we were so irresponsibly pleased by this accomplishment that Airline Agent #2 didn’t even seem bothered when I wanted to take our picture, regardless of the fact that we were holding up an otherwise orderly process of reasonable people getting on a flight from Bangkok to Da Nang.  

And we were able to recharge our tired devices on the fly.   

*

Farmer vs. Medic: Mountain Carry

 

I consider myself something of a carrying specialist.  I have carried water, I have carried wood, I have carried grass, I have carried stinky buffalo-poop fertilizer in a basket and I have carried straw.  I have dropped sacks of rice and recovered and soldiered on with other sacks of rice.  I know carrying, and I know the hills of Nepal.

Relatedly, Bethy is here doing summer-session professional development with our clinical staff, and it just so happens that she spent 10 years as a medic in the New Zealand army.  Recently, we got to talking about the topic of carrying.  It turns out a core skill of army medics is the “fireman’s carry,” and also that this skill may be used either in an emergency with an unconscious or wounded individual or in situations such as on a dance floor, at a bar with friends, or in the middle of the road in Pokhara.

Now Bethy and I are both what you might call competitive individuals–in an entirely healthy and reasonable way, of course.  Out of pure scientific curiosity and in pursuit of expanding human knowledge generally, we got to discussing who could carry whom from the house to the water tap in Kaski.  As Bethy is a scientist and published researcher, and I am a self-made live-in-Nepal-and-start-dental-projects-and-write-stories-er, it became imperative to deploy a proper study on the matter.

Our publication follows herewith.  It is my deep hope that this work will contribute to a deeper understanding of the world and serve as a basis for future investigation.

Phase 1

Phase 2

 

 

 

It’s Not a Problem to Deliver Your Underwear

My friend Ann is here in Pokhara for the summer. She is an IMT therapist and has begun volunteering at the Kaskikot health post, working with the Health Assistant to treat patients using integrative manual therapy. Whenever somebody comes to visit me in Nepal for the first time, I briefly have a renewed sense of chaos, of how from a western sensibility, there is an unnerving feeling of inefficiency and an opacity around how problems get solved. For the most part you don’t rely here on public services, or even private businesses, to pop up with specialized solutions or knowledge in a pinch. You rely on someone’s cousin. To the uninitiated, it’s unclear what people do when things need fixing, and this leaves one with a sinister feeling that small irresolvable inconveniences will accumulate until everything is a hopeless mess and all is lost forever. Therefore, in the presence of first-time visitors I can’t help feeling as though I need to account for a mild but pervasive sense of anarchy that they cannot describe but which, I know, they feel. I don’t know how to explain that there is a different kind of intuitive coherence with other rules.

As for Ann’s visit, everything is basically going great, but one hitch happened early on when she left the bag that contained all her underwear at a hotel in Kathmandu. Also, Ann said it was perfectly fine if I wrote a blog post about her lost underwear. The underwear, while inconvenient but replaceable, was not as much of an issue as the bras that were in the forgotten bag: Ann said her bra size is not that easy to find, and she also said that it’s fine if I write about her bra size too. Replacement of the odd size bras in this environment is one of those opaque things that appears to have no viable solution. The bag needed to be retrieved.

We called Ann’s hotel in Boudanath and determined that they had located the bag of underwear and put it in storage. This was a positive start, however, the next opacity was how the bag would get moved to our district when the mail system exists but doesn’t work according to any particularly obvious or accessible processes. Happily, I was scheduled to go to Kathmandu about a week later. So we rang up Ann’s hotel again and I asked Dorje, the proprietor, if he could hire a taxi to send the underwear to the hotel where I would be staying in Kathmandu. Regarding my hotel, I had previously stayed at the Tibet Peace Guest House only once, but last week after I had called a few times in the process of reserving a room, the hotel clerk and I were officially pals, and when I would call he would answer, “Hello, didi.” I asked the Tibet Peace hotel clerk if he would mind fronting the taxi fare for Ann’s underwear, so that I wouldn’t have to coordinate an exact meeting time with the driver. He said, “Sure didi, no problem.”

“Ann, I have hired a chauffeur for your underwear and the clerk will receive it at my hotel,” I told Ann. She was so excited. Especially for the bras.

I got to Kathmandu and had my meetings and Dr. Bethy arrived and the next day we boarded the plane to Pokhara.

“AH, SHOOT!!” I cried, bonking my forehead against the inside of the double-paned window. A French tourist sitting behind us, who was playing her ukulele in the airplane, became alarmed. She stopped playing her ukulele and leaned forward with her eyes wide.

“Is everything okay?” She asked luxuriously, concerned.

“I forgot Ann’s underwear!” I cried. “Shoot shoot shoot!” Now how would we get it?

The French tourist leaned back and resumed her ukulele playing, and also some singing. The plane was very small, and luckily she was quite a good singer.

Once we’d landed, I called up Ann’s hotel again. Had they forgotten to transport the underwear, I needed to know, or had I left it orphaned for a second time, now at the Tibet Peace Guest House?

“Hello Dorje sir, do you still have my friend’s underwear?” I asked. Dorje revealed that he had planned to send it a day later, today, because the hotel was located in Bouda, a bit of a hike from downtown Thamel where my hotel was, and today they had a driver making an outing anyway. “Oh, I am back in Pokhara now,” I said. “Now what?”

Dorje sir and I pondered the problem for a moment.

“If you know anyone who can bring it to Pokhara, I’ll get your friend’s things to them,” Dorje sir promised. “I will deliver it myself!”

“Ok, I have an idea,” I said. I hung up and walked over to Adam Travel in Lakeside, where we are friends with the owner. Prem often hangs out here in his free time and they book all my tickets. Once, I got to attend a travel agency exhibition in the U.S. with the owner Basu sir.

“Hello Laura didi,” the Adam Travel guys said when Bethy and I walked in. “Ah! Bethy! Hello!” They naturally always know who is traveling with me; the same guys had booked Bethy’s tickets a day earlier, too.

“Hi guys, I was wondering if your Kathmandu office could arrange to have my friend’s underwear sent over. She left all of her underwear at her hotel in Bouda.”

The Adam Travel guys told me that their Kathmandu office is now closed, but the people who used to work at there now work at the Sacred Peace Hotel. Those guys would arrange it. Adam travel proceeded to call Surjet at the Sacred Peace hotel. Surjet said he had some friends at a bus company.

“So,” Adam Travel told me, “They need to bring the items to the Sacred Peace hotel, and you’ll pick it up here. It’s going to be $5 for the cab to the hotel and $5 for the bus to Pokhara. You pay $10.” Where would this be paid? I asked. We’d pay Adam Travel, they said; other people would pay other people in the middle and the debt would accumulate and then we’d pay it off here. No problem.

Sold! I put Adam travel on the phone with Dorje and they discussed all the intermediary checkpoints where someone knows someone who will help reunite the lost underwear bag from Bouda with Ann in Pokhara by Wednesday. We’ve solved the matter within 8 minutes. I wondered why I hadn’t just done this before.

“So there’s bad news, and there’s good news,” I announced that evening to Ann. “The good news is that your underwear will be at Adam Travel in 48 hours. The bad news is I forgot it in Kathmandu.”

“How’s it going to get here?” Ann asked.

“…FedEx.”

*

The Primacy of Snack Time

 

We have had a pretty hectic couple of weeks here, trying to establish good connections in the new province government and chasing meetings that sometimes materialize with little advance warning.  There’s been a lot of dashing about, creating documents that seem like they should be important to somebody, getting signatures and holding coffees with the hope that these activities are all adding up to the “right process.”  The general pace of the office workflow is that the four of us disperse to our desks, and periodically throughout the day we magnetize together in our common area to touch base, update one another on who has had calls with whom Out There, and pump each other up before expanding back out of the common room to our desks.

It has been really nice for me to have this time here to get a feel for the flow of our office without the glare of a tight visiting timeline or imminent program.  This has revealed, among other matters, the primacy of snack time.  Each day Sangita didi arrives around 1:30 and begins a poll on what we want for snacks. Discussion ensues, various viewpoints are considered.  I advocate strongly for buckwheat or rice flour rotis with Nutella and peanut butter, an argument that has recently been strengthened by the purchase of a jar of jam (although, honestly, since when do Nutella arguments need strengthening?).  Others point to the benefits of salty foods such as chowmein and charput (trust me, I realize this should be a non-starter when there’s a vat of Nutella in the kitchen). There are only four of us, but this deciding is nevertheless a substantial process.

In the last three weeks, snacks have been enhanced by the arrival of my friend Ann from Israel.  In the first few days, after I advised her that snack time was the best time to visit our office, and Ann turns out to be a quick study: she arrived promptly on time for the snack poll.  Then–just hours after Ann’s arrival in Pokhara–Sangita put her to work and they hit it off immediately. Ann set learning to make buckwheat rotis while Sangita taught her Nepali words by announcing snack-related vocabulary extremely loudly and waving her hands.  As I mentioned, our office isn’t that big, so from our respective rooms we were all treated to a live cultural soundscape while the two of them, who have an overlapping vocabulary of about two words, tried to communicate the nuances of slicing potatoes and dropping hot batter on to a sizzling frying pan at Sangita’s base-level volume.  Ann, who has the patience of a monk, rose to the occasion by not only making some spectacular rotis, but also by picking up a whole set of Nepali phrases (largely related to eating) amazingly fast. She continues to come over regularly at snack time to help cook rotis while Sangita ecstatically yells words at her.

Who said that Nutella and peanut butter couldn’t get even better?

*

 

 

Dad Explains It

 

Let’s start with background info: my father is both an engineering physicist and a tech entrepreneur. Add to that Olympic athlete and type A+ personality, and you have a world-class Explainer.  My dad is so good at Explaining Things nobody even knew existed, much less needed explaining, that some time ago I started a Dad Explains It video collection.

In this collection you can find such explanations as the anti-slip rubberbander (see below); how to separate an egg using a plastic bottle (a favorite – highly recommend); why an empty wine glass will, albeit unsatisfactorily, substitute for spectacles in a pinch; how to fix your fire truck ladder with glue, and how glue works; how to make a one-flip pancake; advanced paper-lantern lighting in a five-pointed star from Nepal; why it is easy to rip saran wrap in one direction but not the other; and a best-hit, the benefits of curtain velcro.  My mom typically plays a key supporting role in these videos, as herself:

 

On the Explaining front, Dad and Aamaa turn out to be a match made in heaven.  Because Aamaa requires explanations of everything from traffic lights to faucets, and Dad has a limitless endurance – some might even say compulsion – to leave no beautiful creation of the universe Unexplained.  This is extremely handy for all of us.  We girls (Bishnu and Mom and I) just aim them at each other and go about our business.

Over the weekend, we’ve made a family visit to a high rise apartment being constructed in downtown Bethesda. Aamaa is curious about all forms of construction. Like my nephew Jonah, she presses her nose to the window every time we drive past something being built. I decide this comes in the same vein as knowing the origins of food and other things that in Aamaa’s world travel very short distances from creation to use. There are comparatively few things in her life that just appear with no traceable origins–I mean, back in the day, Aamaa and Hadjur Aamaa used to walk to the border of Tibet with baskets to trade for salt. Even modern concrete houses in Kaski are constructed without machinery using materials readily available in the local environment. So a suburban high rise presents a mystery on many levels. How is it all put together? Where does it come from?

First we stop at the building company, where we are provided hard hats. We all agree that Aamaa kills in the hard hat.  (She has to sign a visitor agreement, and since Aamaa can’t write her name, she uses a kind of plus sign – it is always strange to see Aamaa’s incredibly dextrous hands fumble unfamiliarly with a pen.)  Then we head across the street to a service elevator that is in place just for purpose of constructing the high-rise. When Aamaa and I were in Kathmandu a few weeks ago, we visited the third-floor rooftop of a mall. “Holy crap this is high up,” Aamaa proclaimed. “All the buildings in Kathmandu are enormous.”

“Push the button for floor seventeen!” Mom cries as we enter the service elevator.

Aamaa grasps Mom with both hands and the elevator lifts us off the ground with a jolt.

 

We wander the half-built highrise apartment, whose main walls are still open to the sky. Aamaa and Dad are transformed in to a superhero team patrolling Gotham City: there are things that need explaining EVERYWHERE.   The space is divided by empty wall frames which have mammoth-size pallets of insulation stacked up between them. Dad and Aamaa commence an epic geek-out over insulation and plaster, and then shift their nerdfest to the feat of having transported the insulation – and the rest of this stuff – seventeen floors above the ground. Where will the plumbing go? And electricity?

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The construction company employee treats us to a view of the roof. Aamaa has surprised us all with an ominously keen sense of direction in this unfamiliar world. The first few days after she arrived, we were driving around in Connecticut when we approached the drug store on the corner of my street. “This is your street, right?” Aamaa asked, before I had made the turn. I was absolutely baffled that she could get oriented so quickly when most of the visual landmarks are foreign objects with no inherent meaning, like a drug store. Now, on the roof of the high-rise apartment, Aamaa surveys the city below, which she has spent some time touring with Bishnu and me. She extends one finger toward the top of some buildings.

“The subway is in that direction, right?” she asks, correctly.

My Dad becomes ecstatic over Aamaa’s engineer-like spacial acuity. My Mom responds by scanning the horizon herself.

“And over there I see…Machhapuchhre!” she announces.

A few days later we went to go visit Great Falls and the Tow Path and along the Potomac River, where my parents used to take us for hikes on the weekends. Back then we had a special rock bench that my brother and I “discovered,” and which was, for purposes of eating a picnic of peanut butter sandwiches, the target of every summer expedition we made to Great Falls. My dad and I have both rowed many miles on the Potomac River, and on the fourth of July our family would come to the boat house and put on smelly life jackets and watch the fireworks from canoes on the water. This area is part of the circulatory system of our family.  We pulled in to the parking lot at Great Falls with Aamaa.

For some reason that now I can’t completely put together, one of the first things to occur was that Aamaa and Dad got to trading their shade-producing accessories.  I’ll just leave that there.

The only major bodies of water near Kaskikot are the Gandaki River and Phewa Lake. The first, we can cross through the riverbed in our flip flops unless a flood or unusually extreme rain has come through. The second can be crossed by paddle boat in about half an hour. So Great Falls was…great.

And now another confession. For all the years that my family has spent at Great Falls, for all the rowing and firework-watching and picnicking…my brother and I somehow both grew up thinking this was the “Toe Path.”

I know. It’s bad.  Because of the Explaining that is required with Aamaa there, this comes up in conversation.

“What?” my dad says, with the displeasure of a Master Explainer who has realized, at a time when his offspring are grown-ass adults raising children and trying to survive in the world on their own, that something so basic, and so explainable, and so important to the family history as the tow path, NEVER. GOT. EXPLAINED.

Dad explains the history of the C & O Canal as a trade route, complete with a detailed explanation of the the locking mechanisms that allowed canal boats to move upriver. And, swept up in all this Explaining, Dad finally breaks out in to song. This is a thing that happens sometimes.

And so on.  Lead the way, Dad!!

*

*Bonus reel (true undoctored historical evidence)*:

 

Confidence Under Construction

 

For about a year now, the Government of Nepal has been undergoing a decentralization of power. The country has been divided in to five provinces and outfitted with new government employees at the state level. It’s an exciting moment for a project like ours, which is aimed at capacity building in the government health system. Right now entire tier of government in Nepal is literally undergoing construction for the first time.

In the mean time, a large number of essential items are not yet decided even as the new government is deploying its duties. The desks are purchased and people have been assigned to sit behind them – literally – but exactly what these people are responsible for and how their responsibilities are to be executed is still a work in progress. Many operational policies are still not in place, and decision-making power isn’t yet clearly defined between different levels of government. Basically, we are in a car that is being built while rolling down the highway. You’ve probably been there too, right? And I accept that many people would find this alarming.

These people, however, find it AWESOME.

This a great time to be a grassroots organization in Nepal that has been working on health care with previously less-empowered leaders in villages. Oddly enough, Jevaia Foundation now has a lot of specialized knowledge on a key primary health issue that few if any other organizations are working on in Nepal. We have policy ideas that we’ve already modeled in multiple health posts, and there are elected officials in lower levels of government with an interest in getting this model supported by the ministry of health. And right around the corner from us in the capital of Province #4, the policies, budgetary headings, and guidelines that will decide these matters are currently being created.

Our hope is that in coming months, we’ll be able to play a role in influencing some of the new health policy. Currently oral health care in Nepal is available almost exclusively in private practice. The ministry of health doesn’t even have a budget heading for oral health at the primary care level, and in the villages where we work, leaders have cobbled funds from other budget categories to run dental clinics in their Health Posts. In the new provincial system, we’re hoping to organize local officials and communities to demand the creation of oral health budgets from the Ministry of Health at the province level.  Cool, right?

So even though everything’s a bit weird here at the moment, a time of change and uncertainty is of course always, potentially, a time of heightened opportunity. It is certainly a million times better than an unyielding stasis, as anyone who has been in one of those surely knows.

Now let’s bring this all back down to the ground for a second, in my home village of Kaskikot, where the newly elected village leaders reopened the dental clinic we started…which had been closed for SIX YEARS. (Here’s the Washington Post story about our handover of the Kaskikot clinic in 2013.) The new Kaskikot clinic is fully integrated in to the Health Post and financed by the village government. Patients register in the main building and then take a registration ticket to the dental room. Data on patient flow and treatments provided is maintained just like all other primary care services delivered in the government Health Post. Our job is now confined to monitoring quality of care and technical support. It’s AMAZING.

In order to garner backing for this example and its variations in other villages, we’ve been hard at work over the last few weeks meeting people behind desks in the new province government, and then meeting with other people they suggest we meet with. It’s so refreshing to talk with these newly appointed officials and to brainstorm with folks outside government who, like us, have been chipping away at sticky issues for a long time and are trying to sort out what the new system means for these bigger goals. The confusion of the moment is offset by what feels to us like a sense of possibility and movement.  At the same time, it’s important that everyone carry on with a grand performance of confidence, even though nobody is sure what is going on. So, ok, we’re doing that.

For example, recently I thought to invite a couple folks we’d met up to Kaskikot to see the dental clinic one Sunday. They agreed to come. I immediately began worrying over how to make sure that they’d be there on a busy day. The Kaskikot clinic is generally seeing about 8-15 patients a day, which is getting close to full capacity…but it’s also the busy planting season, and it’s raining, and….and anyway, it would just be a bummer if we invited Important People to our clinic and there were not a lot of patients when they arrived.  Maintaining confidence under construction means pulling out all the stops.

Fortunately, the Kaskikot clinic runs on Sundays, and I spend Saturdays at home in Kaskikot. I decided to invest in some advertising. Here’s where we move this story from Important Offices to Aamaa’s Kitchen.

“We’re going to the clinic tomorrow morning,” I informed Didi and Aidan and Pascal over dinner. They were in Kaski last week for school vacation. Didi protested that she needed to leave early morning to cut grass for the buffalo because Aamaa’s leg has been sore. Also, she pointed out, What if it rains later in the day? I told her I was 100% certain that it never rains on Sundays and that, in conclusion, we were all to leave for dental exams at 9:30am sharp.

On Sunday morning I started my rounds early, at Saano Didi and Saraswoti’s houses. Nobody looked like they’d been planning on a dental checkup after breakfast. “C’mon guys, we’ll go together, it will be fun. Malika Didi is coming,” I begged. With dignity, of course. For the greater good.  Then, walking down the ridge toward Deurali, I ran in to Mahendra sauntering home.

“I need you to come to get a dental checkup today,” I said.

“A dental checkup?”

“At the health post. There are some important people coming to see it.”

“Ok Laura didi.”

“Really? You wouldn’t lie to me.”

“I wouldn’t lie to you Laura didi.”

“Hey and bring some of your friends,” I added, testing my luck. Mahendra has a posse of bros that move as a pack.

“Ok Laura didi.”

Mahendra and Saila

“Really?” It seemed suspicious.

“I’ll be there Laura didi.”

“Around 11,“ I said, and continued down the ridge.

I came to the yard of Saili Bouju, who’s married to our local shaman, Bauta Dai, our local shaman. Since I pass  their front yard every time I walk home from the main road, we check in pretty regularly. When I’d arrived on Friday, we had already made a plan to go to the dental clinic Sunday morning.

“Saili Bouju, we’re going for a dental checkup today, right?”

“Yes, yes Laura,” she assured me in her deep raspy voice.

“I’ll be by at 9:45,” I said. “With Malika didi.”

I continued up the walk to the the next two houses, where I made my pitch to Barat’s two sisters-in-law and their families over tea. Ambika Bouju happened to stop by as I was rinsing my teacup.

“Ambika Bouju, come for a dental checkup today.”

“Hey, I’ve been meaning to do that,” she replied, to my great happiness. “I need to take my son in.”

“Today’s the day! There are some Important People coming from Pokhara to see it. We need a crowd.”

“Ok, I’ll be there,” Ambika Bouju agreed.

Out at the main road I came upon Amadev bouju in her yard. She can’t hear very well. “Bouju, let’s go to the health post today,” I said. She smiled and nodded and said, “Sure, Laura.” She’s an overall positive person.

“Really?”

“Ok, ok,” Amadev Bouju said.

“To get your teeth checked.”

“Yep!”

I had a feeling we might not be talking about the same thing, so I hopped down in to the yard to discuss the matter at a shorter distance.  “COME TO THE HEALTH POST WITH ME TO GET A DENTAL EXAM,” I repeated.

“Oh! Dental exam? My teeth don’t hurt.”

“A checkup is important!” I proclaimed. Amadev Bouju rolled over fairly easily. She said she’d meet us at the clinic.

I made my way toward Butu bouju’s house.  Back in the day, when her daughters were younger, we used to have sleepovers and make chocolate chip pancakes over the fire.  Butu bouju was out in the yard and tried to impose more tea upon my already full-of-tea stomach. I was delighted to find out that she’d been thinking to bring her grandkids to the health post for a dental checkup at some point. “I’ll be by with Malika didi to pick you up,” I said, making sure that Didi would have no out now that I’d advertised her all over the village, and headed home.

“I’ve rounded up most of the people in Deurali,” I announced over breakfast. Didi replied that she was going to cut grass. I countered withthe importance of oral hygeine, and of my schemes, and how she loves me. And so on.

We set off mid-morning. Narayan and Amrit, who over to play with Aidan and Pascal, were rounded up and I shuttled the whole gaggle along the edge of the cornfield. They disappeared in to the tall stalks and I turned around to make sure that Didi was following close behind.

Somehow, by the time we got to Govinda Dai’s house, I was already alone again. Didi had peeled off to go retrieve Butu Bouju. Saili Bouju said she had a headache and would go another time, and only after much cajoling said that she’d meet us there in a little while, which I was pretty sure was a way of pacifying me and sending me on my way. When I passed Ambika Bouju’s house, she was nowhere to be found, and even though her daughter said she’d be up the road shortly, it seemed improbable. All four boys—Pascal, Aidan, Narayan and Amrit—had taken off ahead of me down the road while I was trying to recapture our patients, and by the time I reached Govinda’s house in Dophare they were nowhere in sight. I walked in to Govinda’s yard alone, not seven minutes after mission launch.

“Ok Dai, let’s go,” I resigned.  I’d been in this moment at least a thousand times before: everything looks static and bleak. There are no people. It is foggy or rainy or dark or something else that generally conveys that you are all alone. Well, something would work out, or it wouldn’t.

As Govinda dai readied his umbrella, I looked in the road and saw that Mahendra had appeared out of thin air, with a friend. They were carelessly posted by the side of the road, sullen and awesome as usual.

“I told you I was coming, Laura didi,” Mahendra said with casual authority. “You guys go ahead. We’ll be along.”

Near Maula, we caught up with Aidan and Narayan. “Where are Pascal and Amrit?” I asked. “THEY WENT HOME,” Aidan declared triumphantly, beaming. I sighed. Oh well. “I’m going to call your mom,” I said, and took out my phone to dial Didi, who was missing in action. “I HAVE MOMMY’S PHONE,” Aidan proclaimed ecstatically. “IF YOU CALL MOMMY IT WILL RING RIGHT HERE!”

I thought morosely that Didi and Butu Bouju most likely got to chatting and weren’t coming along.

We arrived at the Health Post in a thick fog. The previous night’s rain had left everything squishy and slick. Durga, the clinic assistant, was just getting through the morning disinfection and setup process. The technician Dipendra was nowhere to be found. It was 10:40 and our visitors where scheduled to arrive at 11.

10:50. Dipendra rolled up on his bike.

10:53. Pascal and Amrit came tumbling out of the fog through the gate to the Health Post complex. They tore across the lawn, jumped over the wall, and went back out in to the road to play by the pond until called for their exams.

10:57. Didi materialized from the fog at the gate. Behind her, Butu Bouju was walking and chatting with her grandkids, like spirits emerging out of a cloud. I blinked. There was Saili Bouju behind them.

11:10. A line of non-recruited folks had taken tickets and were awaiting appointments. The bench outside was full, not just with my neighbors, but with the natural flow of weekly patients.

11:15. Ambika Bouju arrived with her son.

11:20. Mahendra and his bros sauntered in to the yard.

11:30. Our two visitors showed up to find a full clinic with a long line of adults, children and elderly patients sitting out a roughly 40 minute wait. Inside the clinic room, Dipendra demonstrated the treatment planning form that was developed during our last professional development in December. I pointed out our infection control protocol on the wall and other features of the clinic protocol that we’ve added to the Health Post setting, like floor coverings, dress, tray numbers and documentation.

We retreated to the local government building next door to talk about our next steps at the province level. By the time we came back outside to get in a car back to Pokhara, it was about 12:00, and the line outside the clinic has grown even further.

“Saili Bouju!” I call across the lawn.

“I told you I was coming!” Saili Bouju shouted back.

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(p.s. I have no idea what’s going on with my weird knome-hairdo in this photo)