To Meet in a Dream

 

We are having a family get together in Asheville, North Carolina. My dad is turning 80 this summer, and it’s Father’s Day, and Bishnu is pregnant with a baby girl. She and Youba arrive on a red-eye from San Francisco, Bethy and I fly in from Connecticut, and my parents drive over from Chapel Hill with Ricky and Julie and the kids. We plop our bags in a cluster of wood-paneled cabins shaded by rustling trees. It is the first time we have all been together since Bishnu got married last year. Now she is Bishnu Subedi Bhatta.

Bishnu and Youba have made the questionable decision of asking for name suggestions. We bat around ideas as we eat ice cream and go to the playground and climb Chimney Rock, where, even though there is an elevator, Bishnu takes the stone staircase up to the top, plodding along step by step while Youba fawns hopelessly over her. At the summit we take a family photo, the North Carolina hills yawning green in to the distance, an endless rustle that is too far off to hear from the top of Chimney Rock, giving way to blue.

In the six years after I first showed up in Kaskikot and before Bishnu came to the US, we would talk on the phone from time to time. It was always morning on one continent, and evening on the other, and in the decade since then I can’t say the phone connection has improved much. Through the static I’d hear about how Saano didi and Mahendra’s families were doing, and whether the millet or corn stalks with their stacked Groucho Marx mustaches had recently been planted or cut down. I’d tell her about New York City, where I was living, and say that Mom and Dad and Ricky were fine. We ended most of our conversations the same way.

“Ok then, well let’s meet in a dream.”

“Where should we go this time?”

And then we’d plan a meeting at the Kalika Temple, or in the kitchen with Aamaa, or on a mat in the yard to paint our nails, or at the festival of Teej. And then we’d say goodbye, and go to sleep to meet in a dream. And always in Nepal.

It has always seemed to me that Bishnu and I were born in to this world with a thread between us, translucent, like the kind used in mobiles or dental floss or to catch carp, because it is unassuming, tensile, and indestructible. The kind that seems as if it can be spooled out forever without reaching the other end that’s buried somewhere in its bottomless coils.

I decide to print the Chimney Rock photo for Father’s Day, which requires sneaking away in to Asheville. We need three copies of the photo for Dad, Ricky and Youba. While I’m out in Asheville I send a text to the family chat to ask if I need to pick up any ingredients for dinner. My mom replies.

Bishnu is cooking dal Bhatta.

I giggle at auto-correct, which has apparently learned Youba’s last name already. My mom means “dal bhaat,” traditional Nepali food–but the more I look at this, the funnier I find it anyway. My fingers tap over the keys.

Does this mean they picked a name for the baby?

It is Youba who replies.

Dal sounds like a boy. Shouldn’t it be Dali?

My mother and I become ecstatic over this. Bishnu’s kid is immediately christened Dali Bhatta. Mostly it is only my mom and me who think this is brilliant. It could be worse, though. My mom called me Loolie-tabooli-tabootznicky…and by “called” I mean “calls.” This is a true story. I was named for my grandfather Louis, and my family turned it turned into Tabootznicky.

We spend the rest of the weekend fishing in the pond, making s’mores on the porch, and turning the kids upside down. Bethy and I are staying in a cabin with Youba and Bishnu, and my mom has brought Bishnu an old notebook along with a pile of belongings from her now-“old” room in Bethesda. We flip through its pages, mystified and awed, like the Dead Sea Scrolls. It contains, in Bishnu’s handwriting: a list of instruments needed for the prehistoric version of the Kaskikot Dental Clinic; draft text for a sticker about fluoride toothpaste to be printed and posted in Kaskikot shops for vendor outreach; and practice answers to questions Bishnu expected to be asked at her visa interview with the US Embassy in 2008. She does a dramatic reading in the living room.

I remember when we bought Bishnu’s first pair of jeans. She looked as out of condition in jeans then as I did in my floppy kurta salwaars, each of us yet to learn to fit our bodies to these foreign garments that we irrevocably longed to inhabit. The more time Bishnu spent attending different trainings and programs that year, the more time I spent at the house with Aamaa alone, learning to move the goats about and cook and plant and cut. When Bishnu was away, Aamaa and I developed a quiet and comfortable flow together. Then Bishnu would come back for a day, arriving on the last bus at 7:30 at night, and I would feel a pang of sadness. The loss of the illusion that I was useful. I would fall back in to following Bishnu around and learning from her for the next twenty four hours. The spool would turn inward, we were drawn together, arguing, sitting in the kitchen, going to the temple, teaching each other about our worlds.

Bishnu always left to go back to her training programs early in the morning. They got progressively further away- Sarangkot, Pokhara, Damauli. America. (I didn’t know it then, but there would be a time when Bishnu was to wake me early in the morning in Bethesda, before going to work in Virginia.) On these mornings I could never motivate myself to wake up any earlier than necessary. Instead I would close my eyes to stave off departure, and then in the dawning bloom of morning, Bishnu would come take my shoulder to say goodbye, and slip out the door to catch the 7am bus. It always seemed, once she had been here, that she was going terribly far away; suddenly, I would be at a lose end. For a few hours, everything seemed empty.

And inevitably, after some period of months, I would spool away to America, and we would meet in a dream.

It is 2019. In my parents’ cabin, I assign my nephew Jonah, Ricky’s eldest and and a lanky eight, to instruct his three and four year old sisters as to how we are going to surprise three fathers with their family photographs. Jonah orders his sisters about for fifteen minutes, placing them behind the curtain, behind a couch, and practicing a chaotic toddler chorus of “Happy Father’s Day!” It is decided that I am to cue the surprise with a casual unsuspicious phrase, for which Jonah has selected “Wasn’t it nice weather today!” With this, my nephew and nieces are to spring from their hiding places and proclaim the happiness of Father’s Day.

The plan goes remarkably well. Youba’s features spread momentarily in to an arrangement of euphoric surprise: he is going to be a dad. And then, a collage of moments fluttering around us. We coo over Dali Bhatta. Jonah and Eli and Nell swing elatedly in the hammock, laughing hysterically over each other, until my dad and Ricky and Youba take their places. The trees around the cabin fall in to a still sheltering, rustling blessings over us, and the sun drops slowly over the hammock, delayed like a water droplet on velvet. We are gorgeously suspended in time.

Bishnu and Youba have booked a 6am flight. So it is still dark when Bishnu comes in to wake me the next morning. I roll over and can almost feel the straw mat under arm as Bishnu whispers, “Bye Laura, we have to go to the airport.” I wrap my arms around her and Dali Bhatta, suddenly both at peace and without coordinates; it is an old feeling, ancient as the notebook and the Dead Sea Scrolls, bottomless as a whole new human being.

The enormous future seems unimaginable in this pre-dawn, where we stretch away in to a miraculous dream, until we are real again.

*

2004

Aging

The second half of our winter professional development is focused on treatment of older adults. Even though a lot of treatment that dental technicians do is in schools, during the weekly dental clinic at the Health Post, they mostly get adult patients. And since most rural adults have had little or no dental care, and likely weren’t exposed to fluoride toothpastes or other preventative measures for their first few decades of life, some of the conditions that present in our rural clinics are pretty extreme. Besides that, tooth loss in older age is common enough that it’s more or less expected.

Of course, our technicians can refer older patients to higher care, and they do. But following up on referrals isn’t always that easy, especially for older folks with reduced mobility. Not to mention that rehabilitation of many mouths we see in elderly patients would require months of ongoing, expensive, complex treatment even in a state-of-the-art dental hospital–something that’s simply is not feasible for the majority population even in a first-world city. So here we are in rural Nepal working in primary care, which is about disease prevention and improving quality of life. But save for the occasional extraction, older adults are mostly left out of the process when it comes to primary oral health care: directly related to the ability to eat, sleep, and participate socially. If we can relieve pain and preserve teeth longer, that seems like a solid contribution.

With this in mind, we wanted to develop a professional development workshop on how the simple techniques that we’re already using – glass ionomer, silver diamine fluoride – can be used to help relieve the diseases experienced in older populations in Nepal. By “we” I mean Bethy since she’s the one obviously who did this because I write stories about teeth and she is a public health dentist. And even if you’re not a dentist or especially interested in cariology, I have to say that how this turned out is really pretty cool.

A few years ago, Bethy and Keri took photos of about 65 people who’d had restorations done in our clinics, and we used these as the basis for a quality-of-care assessment. It resulted in a few different things. One was adding some missing instruments. Another was noticing an apparent pattern among older adults where, around middle adulthood, adult teeth begin to wear rather than decay. It might be caused by anything from an acidic diet, to abrasive brushing with spices, to a lifestyle change like a new medication. The lower part of the tooth near the gums wears down and become loose, causing sensitivity and difficulty eating, and gradually, the teeth simply fall out. These are the adults who, right now, are getting no care at all besides the occasional extraction.  They were the focus of our training.

Our technicians practiced placing glass ionomer restorations on the root-surface lesions, near the gums, that so often lead to tooth loss in older adults. Bethy explained how an event in the life of a middle-aged adult, such as an illness, can cause a simple change like dry mouth that alters the whole environment and leads to deterioration of a previously resilient set of teeth over the next period of years.

I loved this workshop. For the first two hours, instead of looking at teeth, Bethy brought in pictures of older people and the clinical teams simply talked about aging. What makes people old? Are all old people the same? Do they have the same priorities and daily demands and ideas of self? What do we assume when we see someone who we think is “old”? How does a person’s identity factor in to how we work with them to improve their lives? What is our responsibility to someone’s dignity?

In preparing for the workshop, Bethy and I mined our respective photo archives for pictures of elderly people in Nepal and Cambodia. One by one their faces stared out at our group of clinicians, suddenly daring: Who do you think I am?

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In the beginning, most participants had a sort of default position that older people are weaker and less capable of handling dental treatment. But as we went through the photos for well over an hour, stories blossomed. In some cases, they were people whose backgrounds we knew- my neighbors in Kaskikot, steely women I’d photographed during our work after the earthquake in 2015, caretakers and weavers and shopkeepers who’d given interviews in Bethy’s surveys in Cambodia. Bethy used a clever framework called “Go-go, go-slow, no-go” to talk about what each of these people might be expecting or hoping for from a medical professional. I got to laugh about how Hadjur Aamaa has basically no teeth left and gets around pretty slow, but she’ll put one foot in front of the other to get to the house and then frets the entire day, every day, about the dishes or the peas that need to be shelled; it is absolutely vital to her human essence to be busy with something useful. By the end, our clinical teams were musing over what their patients might be thinking about, who they depended on, and who relied on them, what made them human and alive in the world. This was probably a go-slow patient, like Hadjur Aamaa; this one likely a go-go patient ready to sit there all day and get her teeth fixed; this patient probably wasn’t really about treatment, and mainly needed to have his discomfort acknowledged.

The next day, we returned to the same school in Kaskikot to treat patients age 45 and over. (We’re in rural Nepal, 45 is approaching the pre-elderly group…60 is safely considered “aged” and the point is to catch people BEFORE their teeth are gone.) It was exciting to see the same situations we’d learned about the previous day in the real lives of real people and to be able to offer simple treatments that have the potential to forestall tooth loss for years. The teams continued using the App, entering patient data digitally along side the paper forms.

While patients were waiting outside, the father in law of our local Channeler came by for a checkup. I’ve been to see our Channeler a few times – she lives down near Laushidunga, in the direction of Sada Shiva where I taught primary school for a year.  The story that’s told about the Channeler is that she suffered terribly from a kind of delirium for a period of time. She was treated in a hospital, but nothing helped. Then she began to channel spirits. She rebalanced. People travel from all over to see her; I’ve brought a handful of visitors there to connect with people they’ve lost.  Before Bishnu left for the U.S. in 2008, she went to see the Channeler to connect with her father. The Channeler’s husband has a bum knee, and once I gave him my knee brace from CVS, and he always greets me with an old familiarity when we meet in the road up in Deurali.

Anyway, at some point in the afternoon I couldn’t find our technician K.P., and I walked outside to find he was having his palm read in the waiting area. The Channeler’s father in law spent about an hour reading almost everyone’s palm for fifty rupees each. Everyone–our office staff, the field teams, the schoolteachers and other patients–exclaimed over the things he knew: who’s father had died young, who was still to be married, who was destined to successfully stay with one line of work for a long time (one of our clinic assistants! yay!). I didn’t get a turn because by the time I was ready – I’d had my 50 rupees in my pocket for like an hour – he’d had enough with palm reading. Palm reading was over.

Still, my most favorite patient of the day was a 93 year old woman who arrived alone. She was frail, used a walking stick, and barely spoke to anyone even to ask them to move out of the way as she plodded through clusters of people like Moses parting the sea. She wore a jaunty white knit cap that stuck up boisterously on her head. Her entire mouth was completely empty except for one jutting molar with an expanse of exposed root.

“How can we help you?” Hira, the Deurali technician, asked.

“This tooth hurts,” the woman said simply.

 

Hira treated the one tooth with silver diamine fluoride, a completely painless procedure that will hopefully preserve it a while longer and ease her suffering. Then the woman stood up, picked up her walking stick, parted the seas and went home without a word.

*

 

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.

*

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

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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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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The Contract of Attaining

I have been working on rural dental care in Nepal since 2003.  That’s thirteen years.

When I began, the iPhone had not yet been invented.  To call home from Kaskikot, my choices were to wait while Shiva’s dai’s mother rigged up the satellite phone in Deurali, or take what was then a 2.5 hour bus ride to Pokhara and call from an internet cafe.  Now I can Facebook chat while taking breaks during firewood chopping outings.

Our first dental program at the Kaskikot Sub-Health Post, for Sada Shiva Primary School, on May 9, 2004

Our first dental program at the Kaskikot Sub-Health Post, for Sada Shiva School, May 9, 2004

Now in July 2016, Kaskikot’s dingy sub-health post has been upgraded a few times and is a full-scale Health Post.  Someone from almost every house has  left for migrant labor in Malaysia, Dubai, Qatar, or another gulf country, leaving swaths of flush green rice paddies overgrown with grass.  An insurgency overthrew Nepal’s monarchy back in 2006, and the country is still figuring out how to operate a democracy in a place where the young are mostly literate and the middle-aged mostly are not, where rains cut off whole villages from road access during the summer and snow isolates other regions in the winter.  Wireless has long since outpaced plumbing.

Nepal still does not have McDonalds.  Or a majority of schoolbags with zippers that last longer than a year.  Or regularly scheduled elections.  Or, even though it’s the most prevalent disease in the world and influences many of Nepal’s core public health problems, any medicine for dental decay at all in rural places.  Which is still most of the country – and will be for a long time yet.  (See, Wireless vs. Plumbing.)

To the best of my knowledge, our nine rural dental clinics are the only ones of their kind.  There are many aid-funded health care facilities in Nepal, but our clinics are operated by Nepali providers, local to their villages, who practice specialized rural dentistry techniques that are sustainable in limited-resource settings.  We didn’t invent these techniques, but we contextualized them by adding in other pieces like school-based prevention and technician mentoring.  More recently we’ve focused on asking what standard of care these dental technicians can and should be held to within the limitations of environment and training. As a result, we’ve developed considerably more rigorous protocols than are typically applied to permanent rural health services.

Lwang Ghalel Clinic, 2012

Lwang Ghalel Clinic, 2012

This concept is known in international lingo as “rights-based health care.” It’s just the argument that people are entitled to the highest attainable standard of health care within the limitations of context.  This isn’t a new idea, but actually manifesting it through innovation requires a level of patience and detail that could really make you wish you’d gone into a career of monastic asceticism instead.

Fortunately when Roti’s mother came over writhing with a toothache in 2002, I didn’t know I was getting in to a career at all.  At that time I was looking for something I could tell my neighbors in Kaskikot to do when they showed up moaning in pain, which was whenever, not when somebody happened to be rolling by in a mobile clinic.  The answer had to be viable, respectable and available on any random day.  As it turns out, this way of thinking is, by definition, the pursuit of human rights: it seeks a permanent and dignified answer for people, not the implementation of a prefabricated idea.

P1030500That’s how we started combining localized clinics with community awareness programs.  But it took years to realize that wasn’t enough…we had to bring these clinics into the existing health care system of Nepal, a centralized government system that provides a rural Health Post in each village. Basically, our clinics needed to become part of these Health Posts, without losing the benefits of specialization we’d developed.

Nice puzzle.

Since 2012, the biggest challenge we’ve faced in this project is handing over our clinics to local ownership after a two-year set-up and supervision period.  Our first clinic in my own adopted home of Kaskikot, the very place I was motivated to have answers for people, ultimately folded after we ran it for SIX YEARS, treating hundreds of people.  The local government wouldn’t run it.  

Honestly, our advocacy strategy was nonexistent in Kaskikot.  Worse yet, I was the American neighbor-kid, and my efforts were seen as personal.  In Kaskikot, I learned the taste of letting go and swallowed a bitter but essential lesson.

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Our second clinic, in the neighboring village of Sarangkot, inched forward.  It’s been operating on its own since 2012, mostly due the persistence of the dental technician, Dipendra, and clinic assistant, Renuka.  They continue to go to the Sarangkot Health Post every single week, and whenever I’ve visited, they have at least 5-10 patients in a day.  But Sarangkot’s local government only “kind of” funded their clinic.  When I sat in a room full of Sarangkot politicians back in 2012, conducting a (kind-of) “handover” ceremony, there was a Washington Post reporter and photographer present while officials explained that the government just didn’t have any money for this clinic.  I had to say bye and hope for the best…and against the odds, another NGO stepped in and donated a moderate dental budget to the Health Post.  Which allowed the Sarangkot clinic to survive, but saved the health care system of the burden of evolving its priorities on a deeper level.

It’s a quandary, so let’s call the problem like it is.  It feels good to do something and see a result.  But when you have an aid state like Nepal, the do-ers are part of an entrenched structure of dependency that absolves Nepal’s public systems of responsibility. This has been extensively documented, and everyone always seems very dismayed when they’re documenting it.

Okay, but, everyone knows this is the explicit Contract of Producing.  Things mostly run better when the people who decided to start the things are the ones who keep doing them, which mostly is what those people want to do anyway (so that it’s done “right”), and of course the people who didn’t start these things, and probably don’t want to run them, prefer the very same.  Once that’s the way it works, that’s basically what everyone expects and signs up for.  As far as exposés go, it’s not super material.

I am acutely aware of my reluctant participation in this arrangement.  And I too could raise money forever, operate dental clinics one by one in Nepal, and help us all feel like heroes.

But what about the right to the highest attainable care everywhere else?  And besides, what’s “attainable?”  Nepal has a national public health care system that has two key qualities: stability and scale. It’s not famous for quality or agility, but is it capable of incorporating the creations of social innovators and risk-takers to improve its performance one round at a time?

Yes, it has to be.  But only once you break the explicit Contract of Producing.  Instead, there has a be a Contract of Attaining, and then making better things more attainable, and then attaining those.

I think.  I’m still working on this theory before I publish.  But actually, I’m pretty sure about it.

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Salyan Dental Clinic, July 2016

In any case, here we are in 2016, billions of dollars of foreign investment later.  In our corner, we’ve decided to revisit all nine of our dental clinics and focus on their permanent integration in to the government health system.  They’re are all at different stages, from nebulous commitments of local funding to full halts to pre-handover.  We’ve begun by brainstorming with the technicians, and then meeting for coffee with individual village leaders.

Our first stop: Sarangkot…scene of the 2012 Kind-of-Handover.

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Sarangkot Clinic, Post Earthquake

I’ve never visited Sarangkot’s weekly clinic and seen it without patients.  At this point, Dipendra has more specialized experience in rural dentistry in Nepal than pretty much anyone other than the trainers.  He’s treated thousands of children and adults in rural settings, taken refresher trainings, and had at least two clinic audits by a dental surgeon.  But since the kind-of-handover in 2012, we’ve significantly upgraded clinic standards, and the Sarangkot clinic is isn’t supplied for our present quality protocols.  In fact, it’s also being used as a storage room, and the earthquake last year did some interior decorating…and, dusty books. The decor doesn’t really convey, “awesome and critical.”

But here’s our idea. Let’s imagine Sarankgot’s local government was to allocate funding for Dipendra and Renuka, and in exchange, we put about $1000 in to refurbishing the clinic and providing further mentoring.  Sarangkot becomes one of nine places we can invite policy makers in and say: look, this works.  This is awesome and critical.  Here’s another one in Bharat Pokhari, and one in Lwang Ghalel, and…see?  The central health ministry should allocate funding for a rural dentistry specialist in all of its Health Posts.  These progressive village governments are doing it already on their own.

No sweat.  Chop chop.

But it’s important, not just for our issue, primary oral health care, but in principle.  The Contract of Attainment is fairly unpopular, because it’s unmarketable, and we’d all rather feel like heroes.  Somebody has to champion it for its own sake.

IMG_8867Therefore, we’ve spent two long afternoons in the office strategizing, and tomorrow, we’re off to a meeting with local politicians in Sarangkot.  All four of us – me, our Program Director Aamod, and our field officers Dilmaya and Gaurab – are going.  None of us are particularly schooled in political lobbying, but hey, as far as advocating for dental clinic funding in villages in Nepal, I think we’re as good as it gets.  When we met with the Health Post chairman yesterday, he was much more positive than I expected. But things can sound different in a room of people with competing agendas.

So this is where we are in 2016.  We’ve all been thoroughly self-schooled in Virex disinfecting procedures and gloving-regloving infection control, as well as of course the difference between upper molar forceps and an enamel spoon, and we are now embarking on an in-depth immersion experience in citizen advocacy in emerging democracies.

It’s like a career in…in…

…a career in attaining?

Wish us luck!  Time to jump in.

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Salyan Dental Clinic, 2016

Salyan Dental Clinic, 2016

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Walk Home

 

There’s nothing like my first visit to Kaskikot after having recently arrived in Nepal. Granted, sometimes there’s a year in between visits, and in this case I was here just last summer after a long winter stay. But still – today did not disappoint.

I woke up to the charming experience of Pascal throwing his arm on my head. Let’s face it: this room where Didi and Bhinaju live is too small for all of us now, but we are persevering while the house is being built. It is the nights when I share a bed with Aidan and Pascal that I question my judgment in teaching them taekwondo while they are awake.

While Didi made tea, we all lay in bed debating whose fault it was that we’d all spent the night practicing kickball rather than sleeping. Then we documented our morning in selfies.

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Late morning, I met up with some of our graduated Gaky’s Light Fellows for lunch. It was so great to see everyone and hear what they are doing. Sandip is marketing for an online news outlet. Ramesh is deciding where to apply for his bachelor’s in journalism. Nirajan is in Kathmandu, working for Teach for Nepal, and Nischal is entering his second year of bachelor’s. Umesh and Narayan have a solid paid gig singing traditional music each night, and Narayan has his own radio show. Bhagwan is a residential supervisor in a school hostel. When Puja and Asmita finally got there a few hours late, we all made plans to go boating later this week.

Next was getting up to Kaski. With the fuel shortages, this is more challenging than it’s been, as the bus is running infrequently. Not to worry!  I caught the back of a motorcycle ride and then secured a taxi to the bottom of “the jungle path” that climbs straight up from the valley to the house. Forget the bus, man.

So first of all, at the beginning of this path you have to cross over the Gandaki river, which is usually dry at this time of year, but swells in the summer and fall. We used to wade through it, but a few years back it got this nice concrete bridge. So I’m crossing the bridge, and…it just stops in midair. The last half of the bridge is suddenly no longer there.

It takes me a few minutes to negotiate the drop over the ledge of the bridge with a torn ACL in my right knee that won’t let me jump down on to the rocky bed five or six feet below. I make my way over, progress to the bank a short way away, and there at the bottom of the path up to Kaskikot is this leathery guy resting next to a bundle of wood. He looks kind of resigned. I chat with him for a minute and then he asks for help lifting the bundle of wood.

“My son is really strong, he can carry this kind of load,” the man says woefully. “It’s just pretty heavy.”

Nevertheless, the bundle must be lifted, so we give it a try- fortunately I am more qualified than your average random American to hoist a bundle of wood on to someone’s back so it can be slung from their head and carried across a dry riverbed – but it is too heavy, he can’t get upright under the weight. He sets it back down, resumes his seat in the road, and looks resigned again.

“What’s with this bridge?” I ask. “Half of the bridge is missing.”

“I know!” He says. “The other night, I drank up a full belly and came here and fell right off of it.” He points to his forehead and says, “I got a bit of a bump right here.”

IMG_6126“I hear you,” I reply. “I’m not even drunk, and I nearly fell off the bridge too.”

“Just went right over,” he recalls.

“Should we try this bundle of wood again?” I ask.

“Ok, but you have to come around the front and give me a hand.”

I heave the wood on to his back again and this time give him a hand to brace against as a counter balance, and he stands up.

“Thanks, bye,” he says, as if it makes sense that I appeared for this interaction.  Off he goes.

Partway up the jungle path I run in to two kids coming down.  They stop me.

“Where are you from?” they ask me in English.

“America. Where are you from?”

“Puranchaur,” the little boy answers.

“Oh, I’m going to Puranchaur on Tuesday,” I say. It’s one of the villages where we launched last year. I ask what grades they are in: four and eight. “So,” I say to the fourth grader, “do you brush your teeth at school?”

“Yep,” he answers.

“Huh. For about a year, right?”

“A little less than a year,” he says.

“Cool,” I answer, and down the path they go.

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Finally I come out the top of the jungle path and emerge at the water tap in Kaskikot.

“LAURIEEEE!” the ladies cry. “Here you are, just in time for wood cutting to start tomorrow! Last year you came to cut wood, and this year you’re here to cut wood!”

YES. This is the gold medal of the Welcome Olympics. And yes, when I go to cut wood, I understand that it is a memorable experience for all of us.

On my way to the house, a few other people – completely independently – express their approval that I have arrived just in time for wood chopping. I am winning at Nepal.

At last, I drop over the spine of the ridge and there is home. Baby O’Neil is tethered outside, her wet nose pointed quizzically my way; she has grown some brown fur.  The hillside is dotted with jubilant yellow mustard flowers.  There is the familiar line of the Annapurnas rising in to the dusky sky, distant and close. No matter the path that brings me to this piece of land, it always appears the same way, luminous and inevitable.

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