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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